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Presented  by 
William  Bartosh,  D.  0. 


COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


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Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

Microsoft  Corporation 


http://www.archive.org/details/atlastextbookoftOOschuiala 


ATLAS  AND  TEXT-BOOK 


OF 


TOPOGRAPHIC  AND  APPLIED 


ANATOMY 


BY 

OSKAR  SCHULTZE 

PROFESSOR    OF    APPLIED    ANATOMY    IN    VVURZBURG 


EDITED,  WITH   ADDITIONS,  BY 

GEORGE  D.  STEWART,  M.D. 

PROFESSOR   OF   ANATOMY   AND   CLINICAL   SURGERY    IN   THE   UNIVERSITY   AND   BELLEVUE   HOSPITAL 
MEDICAL    COLLEGE,   NEW    YORK 


With  25  Colored  Illustrations  on  22  Lithographic  Plates, 
and  89  Text-cuts,   60  in  Colors 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 
1905 


Copyright,   1905,  by  W.    B.    Saunders  &  Company. 


PRESS     OF 

W.     B      SAUNDERS     &     COMPANY 

PHILADELPHIA 


I 

EDITOR'S  PREFACE 
5 


, 


The  distinguishing  feature  of  Prof.  Oscar  Schultze's  "Topographic  Anatomy"  is  that  it 
contains  the  essentials  of  regional  anatomy  and  omits  the  exceptional  or  relatively  unimportant 
details.  While  it  does  not  claim  to  contain  all  the  important  facts  of  regional  anatomy,  it  may 
justly  claim  that  all  the  facts  contained  have  important  medical  and  surgical  bearings.  Present- 
ing these  in  a  graceful,  forceful,  and  brief  manner,  it  avoids  the  tedium  of  those  books  which, 
attempting  to  include  everything,  become  more  cumbrous  and  even  less  practical  than  the  larger 
text-books  on  systematic  anatomy.  The  editor's  task  has  been  to  make  the  text  conform  to  Eng- 
lish and  American  nomenclature  and  to  add  occasional  notes  which  are  duly  bracketed  and  signed. 
The  translation  of  the  German  text  has  been  done  with  admirable  clearness  and  accuracy  by  Dr. 
W.  Hersey  Thomas. 

Having  already  found  favor  in  Germany,  it  is  hoped  and  believed  that  a  like  reception 
awaits  it  in  America,  and  that  it  will  here  again  realize  the  author's  wish  to  make  a  book  for  those 
who  are  or  who  will  be  doctors. 

May  15,  1905. 


/$(o0k 


PREFACE 


This  book  is  not  written  for  the  anatomist,  but  for  him  who  wishes  to  become  a  physician. 
It  is  the  expression  of  my  method  of  instruction  in  anatomy  which,  assisted  by  renewed  clinical 
studies,  I  have  proved  to  be  most  practical  for  medical  students.  No  claim  is  made  for  anatomic 
completeness,  and  I  am  fully  aware  that  many  anatomic  details  that  are  of  importance  to  the 
physician  have  been  omitted.  As  it  is  my  earnest  wish  to  supply  the  practising  physician  with  a 
foundation  in  anatomy  without  being  too  prolix,  I  shall  be  indebted  to  my  colleagues  for  any  sug- 
gestions they  may  have  to  offer  in  this  respect ;  it  is  the  natural  wish  of  every  author  to  have  an 
opportunity  of  supplying  the  defects  in  his  work. 

To  the  undergraduate,  who  holds  the  first  place  in  my  heart,  I  would  say,  "Think  anatomic- 
ally if  you  wish  to  become  a  physician."  In  the  first  half  of  your  medical  studies  at  the  university 
you  learned  to  know  the  structure  and  development  of  your  body.  Guided  by  lower  forms  of 
life,  you  gained  a  correct  conception  of  your  own  place  in  nature.  You  have  been  taught  to  ad- 
mire the  worth  of  the  body  which  will  later  be  entrusted  to  your  care  when  it  has  become  diseased. 
As  you  go  to  the  bed  of  suffering  every  moment  will  show  you  the  value  of  your  knowledge  of 
anatomy,  and  you  will  see  that  its  employment  must  form  the  foundation  for  accurate  diagnosis. 
You  should  consequently  strive  to  think  anatomically  if  you  wish  to  be  a  good  physician. 

To  the  publishers  I  express  my  thanks  for  their  constant  aid  and  assistance.  The  artist, 
Mr.  Schmitson,  has  proved  his  artistic  sense  in  the  production  of  the  illustrations.  A  small 
number  of  the  pictures  has  been  admirably  executed  by  the  artist,  Mr.  Hajek.  I  am  also  in- 
debted to  Professor  Stohr,  who  kindly  placed  the  anatomic  collection  at  my  disposal.  The  greater 
portion  of  the  dissections  from  which  the  illustrations  have  been  made  were  of  my  own  prepara- 
tion. The  employment  of  His's  models  was  of  the  greatest  value  to  me  in  those  instances  in 
which  original  dissections  were  wanting. 

O.  SCHULTZE. 


LIST  OF  LITHOGRAPHIC  PLATES. 


FACING 
PLATE  PAGE 

i .  The  base  of  the  skull  seen  from  within .  The  various  bones  are  indicated  by  different  colors.  Upon  the  left  side 
the  places  of  exit  of  the  cranial  nerves  are  colored  yellow,  the  places  of  entrance  of  the  most  important  arteries 
red,  and  the  foramina  for  the  chief  veins  blue.  Upon  the  right  side  the  weak  areas  at  the  base  are  outlined 
in  red 22 

2.  The  external  muscles,  arteries,  veins,  and  nerves  of  the  face 26 

3.  The  base  of  the  brain  with  the  twelve  cranial  nerves  and  the  cerebral  arteries 36 

4.  A  median  sagittal  section  of  the  head.     Frozen  section 56 

5 .  A  cross-section  of  the  neck  at  the  level  of  the  thyroid  cartilage.     Frozen  section 62 

6.  A  posterior  view  of  the  opened  head,  neck,  and  trunk  of  a  man.     The  greater  portion  of  the  brain  has  been 

removed;  the  spinal  cord  and  spinal  nerves  as  well  as  the  viscera  and  diaphragm  may  be  seen  in  situ.     From 

a  Leipsic  model  from  nature  (His) 96 

7.  A  posterior  view  of  a  dissection  of  the  thoracic,  and  of  a  portion  of  the  cervical  viscera.     The  relation  of  the 

bronchi,  arteries,  and  veins  at  the  hilus  of  the  lungs.     From  a  Leipsic  model  from  nature  (His) 98 

8.  a.  A  dissection  of  the  mediastinum  seen  from  the  left;  almost  the  entire  left  half  of  the  thorax  has  been  removed 

and  the  left  lung  has  been  cut  away  at  its  root,     b,  The  mediastinum  seen  from  the  right.     Formalin  prepara- 
tions from  a  child 104 

9.  An  anterior  view  of  the  heart.     The  parietal  pericardium  has  been  incised  and  reflected.     Formalin  prepara- 

tion         106 

10.  The  vessels  and  nerves  of  the  mediastinum  and  their  relation  to  the  cervical  viscera.     The  first  illustration  repre- 

sents the  structures  as  seen  from  the  left,  while  the  second  shows  them  as  seen  from  the  right.    Formalin  prep- 
aration         112 

11.  The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy.     Anterior  view.    From  an  accurate  Leipsic  model 

made  from  an  original  dissection  (His) 120 

12.  The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy.     Posterior  view.     From  the  model  of  Plate  1 1 120 

13.  The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy,  seen  from  the  left  and  from  the  right.     From  the 

model  of  Plate  11 122 

14.  The  position  of  the  abdominal  viscera  of  a  boy.     Anterior  view.     The  lungs,  the  heart,  and  the  anterior 

half  of  the  diaphragm  have  been  removed;  the  small  intestine  has  been  cut  away  at  the  root  of  the  mesentery. 
From  an  accurate  Leipsic  model  made  from  an  original  dissection  (His) 128 

15.  The  position  of  the  kidneys,  pancreas,  spleen,  duodenum,  and  colon  as  seen  after  the  removal  of  the  liver, 

stomach,  and  transverse  colon.     From  the  model  of  Plate  14. .    128 

16.  The  position  of  the  thymus  gland,  heart,  liver,  stomach,  spleen,  and  intestines  of  a  fifteen-year-old  girl  as  seen 

from  the  left.     The  left  lung  has  been  removed.     From  a  Leipsic  model  from  nature  (His) 130 

17.  The  position  of  the  pylorus,  cardia,  large  intestine  and  spleen  of  a  fifteen-year-old  girl.     A  deeper  layer  of  the 

model  of  Plate  16 136 

18.  The  position  of  the  liver  (a  portion),  duodenum,  pancreas,  left  kidney,  and  cecum  of  a  fifteen-year-old  girl.     A 

deeper  layer  of  the  model  of  Plate  16 138 

19.  The  male  pelvic  outlet  as  seen  from  without.     From  a  Leipsic  model  from  nature  (His)  with  the  vessels  and 

nerves  sketched  in 1 44 

20.  The  female  pelvic  outlet  as  seen  from  without.     From  a  Leipsic  model  from  nature  (His^l 146 

21.  A  median  sagittal  section  of  the  male  pelvic  region.     From  a  Leipsic  model  from  nature  (His) 148 

22.  A  median  sagittal  section  of  the  female  pelvic  region.     From  a  Leipsic  model  from  nature  (His) 151 

9 


LIST  OF  FIGURES. 


FIG.  PAGE 

i .  The  skull  with  the  three  largest  sensory  nerves  of  the  face  and  the  middle  meningeal  artery facing  18 

2 .  A  cross-section  of  the  calvarium 18 

3.  The  skull  with  the  closed  frontal  sinuses  exposed  by  chiselling  away  the  outer  table  and  the  diploe 19 

4.  The  right  frontal  sinus  opened  from  in  front 20 

5.  The  skull  of  the  newborn  seen  from  above  and  behind 21 

6.  A  cross-section  of  the  layers  of  the  scalp  and  of  the  cranium 25 

7.  The  layers  of  the  scalp,  the  cranium,  and  the  membranes  of  the  brain facing  28 

8.  The  sinuses  of  the  dura  mater.     The  calvarium  has  been  removed  with  the  exception  of  a  central  arch  of 

bone  so  that  the  processes  of  the  dura  mater  have  been  left  intact facing         28 

9.  The  base  of  the  skull  with  the  cranial  nerves,  as  seen  after  the  removal  of  the  brain.     Upon  the  left  side  the 

dura  mater  has  been  left  in  place  and  the  tentorium  cerebelli  incised  so  that  it  is  possible  to  look  into  the 
posterior  cerebral  fossa.  Upon  the  right  side  the  dura  has  been  removed  and  the  places  of  exit  of  the 
nerves  are  visible  at  the  base  of  the  skull facing         32 

10.  The  Gasserian  ganglion  (ganglion  semilunare)  which  has  been  exposed  in  the  middle  cerebral  fossa  by  the 

removal  of  the  dura  mater facing         34 

11.  A  frontal  section  in  the  region  of  the  cavernous  sinus facing         34 

12.  A  frontal  section  through  the  posterior  portion  of  the  head  (frozen  section).     Anterior  view.     The  section 

strikes  the  falx  cerebri,  the  falx  cerebelli,  and  the  tentorium  cerebelli  in  such  a  way  that  the  cranial  cavity 
seems  to  contain  four  apparently  separate  compartments,  in  which  may  be  seen  the  two  cerebral  and  the  two 
cerebellar  hemispheres 36 

13.  Craniocerebral  topography  (after  Kronlein  and  Froriep).     Explanation  in  the  text 37 

14.  The  relations  of  the  vessels  and  of  the  facial  nerve  within  and  beneath  the  parotid  gland.     The  gland  has 

been  divided  by  a  vertical  incision facing  40 

15.  A  frontal  section  of  the  bony  orbits,  of  the  nasal  cavities,  and  of  the  maxillary  sinuses 43 

16.  A  frontal  section  of  the  head  through  the  orbital  cavities  and  the  maxillary  sinuses  (frozen  section) facing  44 

17.  A  horizontal  section  of  the  head  in  the  plane  of  the  palpebral  fissures  (frozen  section).     The  plane  of  section 

passes  through  the  orbits  in  such  a  way  as  to  show  the  entire  length  of  the  optic  nerves  as  well  as  a  portion 
of  the  optic  chiasm.  The  cerebellum  lies  in  the  posterior  cerebral  fossa  and  is  covered  by  the  tentorium 
cerebelli,  which  has  been  left  intact.  In  the  incisura  tentorii  may  be  seen  the  cross-sections  of  the  two 
cerebral  peduncles;  the  entire  cerebrum  has  been  removed 47 

18.  A  portion  of  the  skull  in  which  the  outer  wall  of  the  maxillary  sinus  has  been  removed  in  order  to  show  its 

communication  with  the  nasal  cavity  and  the  relations  of  the  dental  alveoli  to  the  floor  of  the  sinus.  The 
alveoli  have  been  perforated  from  below 51 

19.  The  lateral  wall  of  the  left  nasal  cavity.     Almost  the  entire  middle  turbinated  bone  has  been  excised  in  order 

to  expose  the  structures  and  orifices  situated  beneath  it.  A  piece  has  been  removed  from  the  anterior  portion 
of  the  inferior  turbinated  bone.  The  original  borders  of  these  turbinated  bones  are  indicated  by  dotted 
lines.  The  superior  turbinated  bone  is  intact.  The  orifices  of  the  left  sphenoidal  and  frontal  sinuses  are 
shown  by  arrows facing         52 

20.  The  sublingual  region  in  a  dissected  median  sagittal  section.     The  tongue  has  been  displaced  downward  after 

incision  of  the  oral  mucous  membrane facing         52 

20  A.    View  of  adult  mouth  (modified  from  Spalteholz)    55 

21.  The  pharynx,  opened  longitudinally  from  behind,  with  the  three  anterior  communications:    with  the  nasal 

cavities,  with  the  mouth,  and  with  the  larynx 5^ 

22.  A  sagittal  section  through  the  mastoid  process,  the  external  auditor}-  meatus,  and  the  glenoid  fossa facing         60 

11 


12  LIST  OF  FIGURES. 

FIG.  PACE 

23.  The  temporal  bone  with  the  exposed  tympanum,  tympanic  antrum,  and  mastoid  cells.     The  relations  of  the 

facial  nerve,  internal  jugular  vein,  and  internal  carotid  artery  to  the  wall  of  the  tympanum  may  be  seen. 

The  different  areas  have  been  colored  yellow,  blue,  and  red  respectively facing  60 

24.  The  anterior  cervical  region.     (The  hypoglossal  nerve  has  been  displaced  slightly  downward.) facing  64 

25.  The  submaxillary  and  carotid  triangles facing  66 

26.  A  median  sagittal  section  of  the  neck  (formalin  preparation) facing  68 

27.  The  supraclavicular  region.     The  sternocleido-mastoid  and  the  infrahyoid  muscles  have  been  removed facing  70 

28.  The  infraclavicular  region facing  70 

29.  The  axilla  and  the  lateral  thoracic  wall facing  74 

30.  A  posterior  view  of  the  shoulder  with  the  quadrangular  and  triangular  spaces facing  76 

31.  A  model  of  the  shoulder-joint  and  its  bursas.     The  two  bursas  communicating  with  the  articular  cavity  as 

well  as  the  joint  itself  are  colored  blue.  The  non-communicating  subdeltoid  bursa  is  represented  in  red. 
From  a  Berlin  model facing         78 

32.  A  cross-section  through  the  middle  of  the  arm.     (Hardened  in  formalin.) facing         78 

^.  The  region  of  the  elbow.     (The  musculospiral  nerve  has  been  drawn  up  from  the  depths  and  made  to  assume 

a  more  superficial  position.) facing         80 

34.  A    longitudinal    section    through    the    region    of    the    elbow    and    the    humero-ulnar    articulation    (frozen 

section) facing        82 

35.  The  anterior  aspect  of  the  forearm  above  the  wrist.     The  ulnar  artery  and  nerve  have  been  made  visible 

by  displacing  the  tendon  of  the  flexor  carpi  ulnaris facing         84 

36.  A  cross-section  through  the  middle  of  the  forearm facing         84 

37.  The  muscles,  nerves,  vessels,  and  tendon-sheaths  of  the  palm  of  the  hand.     The  tendon-sheaths  are  colored 

blue.     The  carpal  canal  has  been  opened  by  dividing  the  anterior  annular  ligament facing         86 

38.  Diagrammatic  representation  of  the  joints  of  the  hand 86 

39.  Cervical  ribs.     The  seventh  cervical  vertebra  (indicated  by  the  figure  7)  articulates  with  a  small  cervical  rib 

upon  the  left,  and  with  a  complete  cervical  rib  upon  the  right  which  reaches  to  the  sternum.     The  figures  1 

and  2  indicate  the  first  two  thoracic  vertebras 91 

40.  A  thorax  deformed  by  lacing  (after  Merkel) 92 

41.  A  sternum  with  a  foramen  in  the  lower  portion  of  the  body  of  the  bone 93 

42.  The  anterior  thoracic  wall  seen  from  within.     The  pleura  has  been  removed facing  94 

43.  The  right  intercostal  region.     In  the  upper  of  the  three  intercostal  spaces  represented  the  pleura  is  still  intact; 

in  the  second  it  has  been  removed;  in  the  third,  the  internal  intercostal  muscle  as  well  as  the  pleura  has  been 
taken  away facing         94 

44.  The  diaphragm  and  the  inferior  half  of  the  pericardium  seen  from  above.     Formalin  preparation  (child) 98 

45.  A  diagrammatic  representation  of  the  projections  of  the  heart,  of  the  pleural  limits,  and  of  the  lungs  upon  the 

anterior  thoracic  wall.  The  lung  is  indicated  by  yellow,  and  the  pleura  by  red,  lines.  The  lungs  are  repre- 
sented in  a  state  of  moderate  distention  so  that  their  borders  correspond  to  a  position  midway  between  deepest 
expiration  and  deepest  inspiration facing       100 

46.  A  diagrammatic  representation  of  the  projections  of  the  pleural  limits,  of  the  lungs,  and  of  the  bifurcation  of  the 

trachea   upon   the   posterior   thoracic    wall.     The  lung  is  indicated  by  yellow    and  the  pleura  by  red. 

lines facing       100 

47.  The  median  surface  of  the  right  lung.  ) 

0    rm.  ,.  c  c  »u     1  **  1  f  From  plaster  casts  (His) facing       102 

48.  The  median  surface  of  the  left  lung.      )  r  v       '  /a 

49.  A  view  of  the  dorsal  surface  of  a  frontal  section  of  the  thorax 105 

50.  A  cross-section  of  the  thorax  at  the  level  of  the  nipples.    (The  right  lung  is  somewhat  enlarged  at  the  expense 

of  the  left  one) 107 

51.  The  dorsal  half  of  a  frontal  section  of  the  pericardium  with  the  large  vessels.     An  opening  has  been  made  in  the 

posterior  wall  of  the  pericardium  so  that  the  esophagus  is  exposed.     Formalin  preparation 109 

52.  The  anterior  thoracic  wall  with  the  pericardium  and  the  diaphragm  seen  from  within.     The  dashed  and  dotted 

lines  represent  the  anterior  pleural  limits;  between  them,  at  the  level  of  the  fifth  left  costal  cartilage,  is  the  site 

for  aspiration  of  the  pericardial  cavity  (formalin  preparation) no 

53.  A  cross-section  of  the  thorax  at  the  level  of  the  tracheal  bifurcation  (frozen  section)      The  left  lung  was  dis- 

eased at  its  apex  and  diminished  in  size  as  a  whole;  the  right  lung  was  correspondingly  enlarged in 

54.  The  pharynx,  esophagus,  trachea,  and  aorta  seen  from  behind facing       114 


LIST  OF  FIGURES. 


!3 


n<!'  PAGE 

55.  A  diagrammatic  representation  of  the  communications  between  the  superior  and  inferior  vena  cavae  and  the 

portal  vein facing       122 

56.  The  inferior  half  of  the  anterior  abdominal  wall  as  seen  from  within.     The  pelvis  is  shown  in  frontal  section. 

The  greater  portion  of  the  peritoneum  has  been  left  intact,  but  portions  of  it  have  been  removed  upon  the 
right  from  the  internal  abdominal  ring,  upon  the  left  from  the  epigastric  vessels,  the  lateral  umbilical 
ligament,  and  the  vas  deferens,  and  in  the  middle  line  from  the  median  line  from  the  median  umbilical 
ligament facing       124 

57.  In  the  left  iliac  fossa  the  layers  of  the  abdominal  wall  are  shown,  the  dissection  exposing  the  sigmoid  colon. 

The  recti  muscles  are  divided  and  the  urinary  bladder  has  been  made  visible  above  the  symphysis  without 
injuring  the  peritoneum.     Upon  the  right  side  there  is  an  internal  inguinal  hernia facing       124 

58.  The  inferior  half  of  the  anterior  abdominal  wall  with  the  hernial  regions  as  seen  from  within  and  above.    At  the 

site  of  the  femoral  ring  is  the  sac  of  a  femoral  hernia.  The  internal  inguinal  fossa  is  limited  internally  by  a 
sharply  bordered  fold  (falx  inguinalis),  which  belongs  to  the  transversalis  abdominis  muscle.  (Frozen 
formalin  preparation.) 124 

59.  First  diagram  for  the  representation  of  the  peritoneum.     The  bursa  omentalis  is  outlined  in  red,  the  remaining 

portion  of  the  peritoneal  cavity  in  blue facing       126 

60.  Second  diagram  for  the  representation  of  the  peritoneum.     As  in  Fig.  59,  the  bursa  omentalis  is  outlined  in 

red facing       126 

61.  The  porta  hepatis,  the  pancreas,  the  duodenum,  the  kidneys,  the  spleen,  and  the  suprarenal  bodies  with  their 

vessels.     (Formalin  preparation.) facing  132 

62.  A  cross-section  of  the  trunk  at  the  level  of  the  xiphoid  process  of  the  sternum 132 

63.  The  liver,  seen  from  below facing  134 

64.  The  position  of  the  structures  at  the  porta  hepatis facing  134 

65.  The  left  kidney  seen  from  in  front facing  140 

66.  The  right  kidney  seen  from  in  front facing  140 

67.  Anterior  view  of  the  relations  of  the  right  kidney facing  140 

68.  Anterior  view  of  the  relations  of  the  left  kidney facing  140 

69.  A  cross-section  of  the  abdomen  in  the  inferior  renal  region 141 

70.  A  sagittal  section  of  the  female  pelvis  with  the  anteroposterior  pelvic  diameters 144 

71.  The  bladder,  the  ureters,  and  the  seminal  vesicles  exposed  from  behind  by  a  frontal  section  of  the  pelvis. 

Upon  the  left  side  there  is  an  external  inguinal  hernia.  Upon  the  right  side  the  peritoneum  has  been  al- 
most entirely  removed facing       148 

72.  The  relation  of  the  ureter  to  the  uterine  artery  and  to  the  cervix  and  vagina.     The  left  half  of  a  specimen  in 

which  a  median  section  of  the  female  pelvic  viscera  has  been  made.     The  broad  and  round  ligaments  have 

been  incised  and  the  uterus  displaced  upward  and  backward facing       153 

73.  The  lateral  pelvic  wall  of  the  female.     The  posterior  layer  of  the  broad  ligament  has  been  incised  at  the  side  of 

the  recto-uterine  pouch.     The  uterus,  with  the  tube  and  ovary  has  been  displaced  anteriorly  and  the  rectum 

has  been  pushed  posteriorly facing       153 

74.  A  diagrammatic  representation  of  an  anterior  view  of  the  hip-joint.     The  attachment  of  the  capsular  ligament 

corresponds  to  the  linea  intertrochanterica  (red).  The  weaker  portions  of  the  capsule  are  colored  yellow.  A 
detailed  description  will  be  found  in  the  text facing       155 

75.  A  diagrammatic  representation  of  a  posterior  view  of  the  hip-joint.     The  attachment  of  the  capsular  ligament 

(red  line)  is  situated  above  the  intertrochanteric  crest.     The  weak  areas  in  the  posterior  portion  of  the  capsule 

are  colored  yellow facing       155 

76.  A  diagrammatic  representation  of  the  lacuna  musculorum,  of  the  lacuna  vasorum,   and  of  the  femoral 

ring facing  155 

77.  The  subinguinal  region  with  the  vessels  and  lymphatic  glands  lying  upon  the  deep  fascia facing  157 

78.  The  topography  of  the  deep  gluteal  region facing  157 

79.  The  anterior  femoral  region - facing  159 

80.  The  exposure  of  the  femoral  artery  before  its  entrance  into  Hunter's  canal facing  159 

81.  The  subperitoneal  exposure  of  the  external  iliac  artery.     Below  Poupart's  ligament  the  femoral  vessels  have 

also  been  exposed feeing       159 

82.  A  cross-section  above  the  middle  of  the  thigh facing       161 

83.  The  popliteal  space facing       163 


14  LIST  OF  FIGURES. 

FIG.  PAGE 

84.  The  knee-joint  after  the  injection  of  a  blue  mass  into  the  articular  cavity;  the  bursas  communicating  with  the 

joint  are  also  filled  with  the  blue  injection.     The  non-communicating  bursas  have  been  injected  with  a  red 
mass.     From  a  Berlin  model facing       163 

85.  The  nerves  and  vessels  upon  the  anterior  aspect  of  the  leg  and  foot facing       165 

86.  A  cross-section  through  the  upper  half  of  the  leg facing       165 

87.  The  plantar  aspect  of  the  foot.     The  flexor  brevis  digitorum  muscle  has  been  divided  and  portions  have  been  cut 

out  of  the  flexor  longus  digitorum,  adductor  hallucis,  and  flexor  brevis  hallucis  muscles facing       167 

88.  A  frontal  section  of  the  talocrural  and  talocalcaneal  articulations facing       169 

89.  A  diagrammatic  representation  of  the  joints  of  the  foot facing       169 


CONTENTS. 


PAGE 

The  Head 17 

The  Cranial  Region 17 

The  Cranium 17 

The  Scalp 24 

The  Membranes  of  the  Brain 28 

Craniocerebral  Topography 35 

Questions 38 

The  Facial  Region 39 

The  Face 39 

The  Orbital  Cavity 42 

The  Nasal  Cavity 48 

The  Oral  Cavity 54 

The  Organ  of  Hearing 59 

Questions 60 

The  Neck 61 

The  Upper  Extremity 72 

The  Shoulder 72 

The  Upper  Arm 77 

The  Region  of  the  Elbow 79 

The  Forearm 81 

The  Hand 84 

Questions 88 

The  Thorax 89 

The  Thoracic  Wall 89 


PAGE 

The  Contents  of  the  Thorax 99 

The  Mediastinum 104 

Review  Questions 117 

The  Abdomen 118 

The  Abdominal  Wall 118 

The   Peritoneum 125 

The  Contents  of  the  Abdomen 128 

Review  Questions 142 

The  Pelvis 143 

The  Pelvic  Walls 143 

The  Pelvic  Cavity  in  the  Male 147 

The  Pelvic  Cavity  in  the  Female 150 

Review  Questions 154 

The  Lower  Extremity 155 

The  Region  of  the  Hip 155 

The  Thigh 159 

The  Region  of  the  Knee 162 

The  Leg 165 

The  Foot 168 

Review  Questions 171 

Index 1 73 


15 


TOPOGRAPHIC 

AND 

APPLIED    ANATOMY. 


THE  HEAD. 

The  study  of  the  practical  anatomy  of  the  head  has  for  its  essential  foundation  a  knowledge 
of  the  bones  of  the  skull  (Fig.  i).  The  cranium,  surrounding  the  brain  like  a  capsule,  is  dis- 
tinguished from  the  face,  which  holds  relation  to  the  beginnings  of  the  intestinal  and  respiratory 
tracts  and  to  important  sense-organs,  particularly  to  the  organ  of  vision.  The  external  boun- 
daries between  the  cranium  and  the  face  are  formed  by  the  superior  margin  of  the  orbit,  the 
zygoma,  and  the  external  auditory  meatus.  In  conformity  with  these  divisions  of  the  skull,  the 
head  is  subdivided  into  a  cranial  region  and  a  facial  region. 

THE  CRANIAL  REGION. 
THE  CRANIUM. 

The  cranium  is  formed  by  the  following  bones : 

(a)  Four  single  bones:  (i)  The  occipital,  (2)  the  sphenoid,  (3)  the  ethmoid,  (4)  the  frontal. 

(b)  Two  paired  bones:  (1)  The  parietal,  (2)  the  temporal. 

Portions  of  some  of  these  bones  are  also  found  in  the  facial  group,  the  greater  portion  of  the 
ethmoid,  for  example.  The  relations  of  these  bones  become  clearer  if  we  remember  that  the 
broad  sagittal  ring  formed  by  the  single  bones  is  open  above  and  is  converted  into  a  closed  chamber 
by  the  broad  frontal  ring  of  the  paired  bones,  which  is  open  below.  The  superior  or  arched 
portion  of  the  cranium  is  known  as  the  vertex  or  vault,  while  the  inferior  or  flatter  portion  is 
called  the  base  of  the  skull.  The  plane  of  the  base  of  the  skull  dips  posteriorly  and  forms  the 
chord,  so  to  speak,  of  the  large  arc  of  the  cranial  vault. 

The  thickness  of  the  cranium  is  of  great  importance,  particularly  with  reference  to  the  prog- 
nosis of  injuries.  It  varies  with  age,  with  the  individual,  and  above  all  with  location.  Between 
the  extremes  of  the  so-called  paper-skulls,  scarcely  two  millimeters  thick,  and  those  skulls  which 
are  called  hypertrophic,  measuring  one  centimeter  or  even  more  in  thickness,  there  are  many  in- 
termediate degrees.  The  average  thickness  of  the  cranial  vault  is  five  millimeters.  Disregard- 
ing the  thin  portions  of  the  base  (see  page  22),  a  knowledge  of  which  is  particularly  important  for 
the  understanding  of  fractures  in  this  situation,  local  thinnings  of  the  skull  are  produced: 
2  17 


1 8  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

FlG.  i. — The  skull  with  the  three  largest  sensory  nerves  of  the  face  and  the  middle  meningeal  artery. 

(i)  By  abnormally  developed  Pacchionian  depressions,  situated  chiefly  near  the  median  line 
of  the  cranial  vault  and  due  to  marked  proliferation  of  the  villi  of  the  arachnoid,  that  is,  the 
Pacchionian  bodies  (see  page  33).  These  proliferations  may  lead  to  perforation  of  the  bones, 
even  appearing  beneath  the  scalp  as  small  tumors  which  are  reducible  upon  pressure ;  or,  in  rare 
instances,  they  may  cause  the  bone  to  bulge,  producing  palpable,  immovable,  and  hard  bony 
enlargements  (in  contradistinction  to  sebaceous  cysts  of  the  scalp  which  originate  in  the  sebaceous 
glands  and  are  movable  upon  the  underlying  bone).  (2)  By  the  middle  meningeal  artery  (see 
page  29),  which  is  deeply  imbedded  on  the  inner  surface  of  the  cranial  wall,  sometimes,  how- 
ever, reaching  almost  to  the  outer  surface  of  the  cranial  vault  or  even  perforating  the  external 
table  and  producing  marked  external  hemorrhage  when  injured.  (3)  Rarely  by  varicose  dilata- 
tions of  the  diploic  veins  (see  below),  which  lead  to  atrophy  of  the  bone,  and  also  by  the  spheno- 
parietal sinus  (see  page  32),  which  may  be  deeply  imbedded  in  the  cranial  vault  somewhat 
posterior  to  the  coronal  suture.     (4)  By  increasing  age,  which  makes  the  skull  considerably 


External 
plate 

Diploe 

■• ...  >  '-' 

PM 

Internal  plate 
Fig.  2. — A  cross-section  of  the  calvarium. 

thinner,  lighter,  and  more  fragile,  so  that  places  which  were  previously  thin  (e.  g.,  the  orbital 
plate  of  the  frontal,  the  lachrymal,  the  os  planum  of  the  ethmoid,  the  posterior  cranial  fossa, 
the  inner  wall  of  the  maxillary  sinus)  are  converted  into  foramina  by  absorption. 

The  sawed  cross-section  of  the  vertex  reveals  two  compact  layers  of  bone  which  enclose  a 
stratum  of  spongy  tissue.  The  external  plate — averaging  1.5  mm.  in  thickness — as  well  as 
the  internal  plate — about  0.5  mm.  thick — have  numerous  fine  pores  for  the  passage  of  the  per- 
iosteal vessels.  There  is  no  sharp  line  of  division  between  either  table  and  the  enclosed  diploe, 
which  is  filled  with  red  bone-marrow.  Fractures  of  the  inner  table,  such  as  the  so-called  stellate 
fractures,  or  splinterings  of  the  inner  table  without  concomitant  injury  of  the  outer  table  are  not 
due  to  a  greater  brittleness  of  the  inner  table,  but  to  its  thinness  and  to  its  shorter  radius  of 
curvature. 

The  venous  blood  of  the  bone  collects  in  the  diploic  veins  which  are  situated  in  canals  in  the 
diploe.  The  diploic  veins  are  divided  into  the  frontal,  anterior  temporal,  posterior  temporal,  and 
occipital.     They  are  subject  to  considerable  variation,  and  hemorrhage  from  them  after  injury 


f'g-  '. 


Coronal  suture 


Great  wing  of  the 

sphenoid 

Anterior  branch  of  the 

middle  meningeal 

artery 

Squamous   portion    of 

the  temporal  bone 

Posterior  branch  of  the 

middle   meningeal  artery 

Zygomatic  process  of 

the  temporal  bone 

Glenoid  fossa 

Condyloid   process   of 

the  mandible 

Tympanic  plate 

External  auditory 

meatus 


Mastoid  process 


Supra-orbital  nerve 

Orbital  plate  of  the  fronta 

bone 
Nasal  bone 

Anterior  ethmoidal  foramen 
Lachrymal  bone 
Os  planum  of  the  ethmoid 
Posterior  ethmoidal  foramen 

Optic  foramen 

Infra-orbital  nerve 

Left  infra-orbital  foramen 

Malar  bone 


Mental  nerve 


THE    CRANIUM. 


19 


Frontal  sinuses 


Internal 
plate 


is  not  of  great  importance.     In  opening  the  skull  with  the  chisel  or  in  trephining  no  attempt  is 
made  to  avoid  them. 

At  the  thin  places  in  the  cranium,  such  as  the  squamous  portion  of  the  temporal  bone,  the 
bottom  of  the  posterior  cranial  fossa,  etc.,  the  diploe'  is  absent  and  the  two  tables  are  in  contact 
with  each  other.     The  diploe  may  also  undergo  more  or  less  atrophy  in  the  aged. 

In  the  frontal  bone  the  two  tables  become  widely  separated  on  either  side  of  the  glabella 
enclosing  the  frontal  sinuses,  which,  next  to  the  maxillary  sinuses,  are  the  largest  of  the  accessory 
air-cavities  in  communication  with  the  nose  (see  Fig.  3).  Between  the  inner  table  and  the  an- 
terior wall  of  the  frontal  sinus  there  is  still  a  thin  layer  of  diploic  tissue,  while  the  inner  (posterior) 
wall  of  the  frontal  sinus  is  formed  by  the 
inner  table.  The  frontal  sinuses  are  paired 
cavities  and  are  separated  by  a  bony 
septum  which  is  not  often  situated  exactly 
in  the  median  line.  Incomplete  septa 
projecting  inward  very  frequently  make 
these  sinuses  multilocular,  in  which  case 
they  may  attain  an  enormous  size.  The 
sinus  o.pens  into  the  middle  nasal  fossa 
(see  Fig.  19),  but  the  orifice  can  rarely  be 
sounded  from  the  anterior  nares  during 
life.  In  the  dreaded  catarrh  of  the  frontal 
sinuses  with  subsequent  empyema,  it  con- 
sequently follows  that  relief  must  be  given 
by  chiseling  through  the  bone  above  the 
supraorbital  margin,  never  forgetting  that 
the  anterior  wall  of  the  sinus  is  much 
thicker  than  the  posterior  one  (see  Fig.  4). 
After  this  has  been  done,  an  attempt  may 
be  made  to  re-establish  the  normal  com- 
munication with  the  nasal  cavity  from 
above.  The  opening  of  the  frontal  sinus 
from  without  may  lead  to  a  subcutaneous 
emphysema  of  the  frontal  region,  since  the  air  from  the  nasal  chambers  gains  access  to  the 
subcutaneous  tissues  of  the  forehead.  Large  frontal  sinuses  frequently  extend  posteriorly  into 
the  roof  of  the  orbit.  The  severe  pain  attendant  upon  catarrhal  inflammation  of  the  frontal 
sinus  is  explained  by  the  rich  supply  of  the  lining  mucous  membrane  from  the  nasal  nerve. 

The  jonlanelles  are  membranous  portions  of  the  vertex  of  the  fetus  and  of  the  newborn  at  the 
junction  of  several  bones  where  ossification  takes  place  at  a  comparatively  late  date.  We  dis- 
tinguish two  single  and  two  paired  fontanelles  (see  Fig.  5). 

The  single  fontanelles  are  the  most  important : 

1.  The  large  or  frontal  jontanelle—  This  is  diamond-shaped,  and  in  the  new-born  is  situated 
between  the  still  ununited  halves  of  the  frontal  bone  and  the  two  parietal  bones.     Like  the  frontal 


Fig.  3. 


—The  skull  with  the  closed  frontal  sinuses  exposed  by 
chiseling  away  the  outer  table  and  the  diploe. 


20 


TOPOGRAPHIC   AND   APPLIED   ANATOMY. 


suture,  it  does  not  close  until  the  second  year,  but  may  remain  open  for  a  much  longer  period. 
During  the  birth  of  the  child  it  is  utilized  by  the  obstetrician  to  determine  the  position  of  the  head. 
2.  The  small  or  occipital  fontanelle. — This  has  the  shape  of  an  obtuse-angled  triangle  and 
lies  between  the  highest  point  of  the  occipital  bone  and  the  two  parietal  bones.     During  birth 
this  fontanelle  is  usually  closed,  but  the  physician  can  nevertheless  recognize  it  by  the  fact  that  the 
compression  of  the  child's  skull  pushes  the  occipital  bone  beneath  the  edges  of  the  parietal  bones. 
The  paired  fontanelles,  less  important  and  usually  closed  at  birth,  are: 
i.  The  antero-lateral  fontanelle,  between  the  frontal  and  parietal  bones  on  the  one  side  and 
the  great  wing  of  the  sphenoid  and  the  squamous  portion  of  the  temporal  on  the  other. 


Scalp - 


Pericranium  - 
Mucous  membrane 

of  frontal  sinus 

Opening  of  frontal . 

sinus 

Anterior  wall  of  - 

frontal  sinus 


\ 


X 


Fig.  4. — The  right  frontal  sinus  opened  from  in  front. 


2.  The  posterolateral  fontanelle,  between  the  mastoid  portion  of  the  temporal,  the  parietal, 
and  the  occipital  bones.  In  the  new-born  a  fissure  extends  from  this  fontanelle  into  the  occipital 
bone,  which  has  been  falsely  attributed  to  the  effect  of  traumatism,  but  which  really  marks  the 
original  boundary  between  that  portion  of  the  occipital  bone  which  is  laid  down  in  cartilage  and 
that  which  is  laid  down  in  membrane. 

The  occurrence  of  supernumerary  sutures  and  Wormian  bones  in  the  vault  of  the  skull  is  of 
considerable  importance  from  a  practical,  and  particularly  from  a  medico-legal,  standpoint,  since 
they  have  been  mistaken  for  fractures.     Among  these  may  be  mentioned  the  frequently  persistent 


THE    CRANIUM. 


21 


frontal  suture,  the  numerous  Wormian  bones  in  the  lambdoid  suture,  the  so-called  fontanelle- 
bones  occurring  in  the  paired  and  in  the  single  fontanelles,  and  the  interparietal  bone,  which  corre- 
sponds to  that  portion  of  the  occipital  bone  which  is  laid  down  in  membrane. 

The  base  of  the  skull  is  formed  by  the  following  bones:  The  frontal,  the  ethmoid,  the 
sphenoid,  the  temporal,  and  the  occipital. 

The  points  of  exit  of  the  twelve  cranial  nerves  from  the  base  of  the  skull  (indicated  in  Plate 
i  by  yellow)  are:  (i)  The  cribriform  plate  of  the  ethmoid  which  lodges  the  olfactory  bulb  and 
which  gives  passage  to  the  olfactory  filaments  on  their  way  to  the  nasal  fossa.  (2)  The  optic 
foramen  for  the  optic  nerve  (and  the  ophthalmic  artery  arising  from  the  internal  carotid).  (3) 
The  sphenoidal  fissure  for  the  oculomotor,  trochlear,  ophthalmic  division  of  the  fifth,  and  the 
abducent  nerves.  (4)  The  foramen  rotundum  for  the  superior  maxillary  division  of  the  fifth 
nerve.     (5)  The  foramen  ovale  for  the  inferior  maxillary  division  of  the  fifth  nerve.     (6)  The 


Frontal  fontanelle 

Frontal  bone 
Coronal  suture 

Anterolateral  fontanelle 

~- Great  wing  of  sphenoid 

^ Squamous  portion  of 

temporal  bone 
m Zygoma 

Lower  maxilla 

Mastoid  portion  of  tem- 
poral bone 


Fig.  5. — The  skull  of  the  new-born  seen  from  above  and  behind. 


internal  auditory  meatus  for  the  facial  and  auditory  nerves.  (7)  The  jugular  foramen,  anterior 
portion,  for  the  glossopharyngeal,  vagus,  and  spinal  accessory  nerves  [in  the  order  named  from 
before  backward  between  the  inferior  petrosal  sinus  in  front  and  the  lateral  sinus  behind. — 
Ed.].     (8)  The  anterior  condyloid  foramen  for  the  hypoglossal  nerve. 

The  points  0}  entrance  0}  the  main  arteries  (designated  in  Plate  1  by  red)  are :  (a)  To  the  brain: 
The  foramen  magnum  for  the  two  vertebral  arteries  (n)  from  the  subclavian,  and  the  carotid 
canal  in  the  petrous  portion  of  the  temporal  bone  for  the  internal  carotid  (9).  (b)  To  the  dura 
mater,  i.  e.,  to  the  internal  periosteum  of  the  cranial  vault  and  to  the  vault  itself:  The  foramen 
spinosum  in  the  great  wing  of  the  sphenoid  for  the  middle  meningeal  branch  of  the  internal  max- 
illary artery  (10). 

The  venous  blood  from  the  brain  is  collected  in  the  cerebral  sinuses  and  leaves  the  cranial 


22  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

PLATE  1. 

The  base  of  the  skull  seen  from  within.  The  various  bones  are  indicated  by  different  colors.  Upon  the  left  side 
the  places  of  exit  of  the  cranial  nerves  are  colored  yellow,  the  places  of  entrance  of  the  most  important  arteries  red, 
and  the  foramina  for  the  chief  veins  blue.     Upon  the  right  side  the  weak  areas  at  the  base  are  outlined  in  red. 

cavity  through  the  posterior  compartment  of  the  jugular  foramen  (designated  in  the  illustration 
by  blue,  12). 

Our  attention  should  also  be  directed  to  the  emissary  foramina  (Santorini),  which  are  aper- 
tures in  the  cranium  giving  passage  to  venous  connections  between  the  external  veins  of  the  head 
and  the  cerebral  sinuses.  The  blood  in  the  emissary  veins  passes  from  within  outward,  so  that 
these  veins  relieve  the  cerebral  sinuses,  particularly  when  the  intracranial  blood-pressure  is  in- 
creased. This  explains  the  rationale  of  the  withdrawal  of  blood  from  the  scalp  for  the  purpose 
of  relieving  intracranial  congestion  (for  example,  behind  the  ear  in  the  region  of  the  mastoid 
emissary).  [Through  them  infection  is  sometimes  carried  from  the  surface — as  in  the  case  of 
erysipelas  and  other  inflammatory  diseases  of  the  scalp — to  the  sinuses,  causing  thrombosis 
or  meningitis. — Ed.]  The  emissary  foramina  are  subject  to  very  great  variations.  We  dis- 
tinguish: (1)  The  parietal  foramen  to  either  side  of  the  sagittal  suture  in  a  line  connecting  the 
parietal  eminences.  It  leads  to  the  superior  longitudinal  sinus  and  may  be  absent  upon  one 
or  both  sides.  (2)  The  mastoid  foramen  for  the  vein  connecting  the  occipital  veins  with  the  lateral 
sinus  (it  also  transmits  a  meningeal  branch  of  the  occipital  artery  to  the  dura  mater)'.  This 
foramen  is  above  the  base  of  the  mastoid  process,  two  finger-breadths  behind  the  external 
auditory  meatus,  and  is  the  largest  and  most  constant  of  all  the  emissary  foramina  (see  Plate  1, 
14).  When  the  jugular  foramen,  the  normal  point  of  exit  for  the  venous  blood,  is  narrowed  (as 
in  a  rachitic  closure  of  this  foramen,  for  example)  the  mastoid  foramen  is  so  much  enlarged  that 
it  is  sufficient  to  allow  the  venous  blood  to  escape  from  the  cranial  cavity.  (3)  The  posterior 
condyloid  foramen,  in  the  condyloid  portion  of  the  occipital  bone,  connects  the  deep  veins  of  the 
neck  with  the  lateral  sinus  (see  Plate  1,  13).  (4)  The  occipital  foramen  in  the  external  occipital 
protuberance.  This  is  insignificant  and  frequently  replaced  by  numerous  small  foramina  which 
transmit  connections  between  the  occipital  veins  and  the  torcular  Herophili. 

The  practical  study  of  the  base  of  the  skull  with  the  foramina  for  the  passage  of  the  nerves 
and  vessels  is  important  not  only  on  account  of  the  neuralgia  and  paralyses  following  bone-disease, 
but  also  in  the  diagnosis  of  basal  fractures,  intracranial  tumors,  and  the  extension  of  disease  of  the 
middle  ear  to  the  cranial  cavity.  In  view  of  the  fact  that  the  modern  surgeon  operates  upon  the 
base  of  the  skull  from  within  [as  well  as  without. — Ed.]  the  cranial  cavity,  an  exact  knowledge 
of  the  topography  of  this  region  is  most  essential. 

Those  portions  of  the  base  which  are  thin  or  relatively  weak,  on  account  of  the  presence  of 
numerous  foramina,  are  particularly  predisposed  to  fractures  and  injuries  in  general.  They  are 
indicated  in  Plate  1  by  dotted  lines  and  are  found  in  the  following  situations.  In  the  anterior 
cranial  fossa :  The  cribriform  plate  of  the  ethmoid  bone  and  the  orbital  plate  of  the  frontal  bone 
(a),  particularly  in  the  depressions  which  lodge  the  frontal  convolutions.  In  the  middle  cranial 
fossa:  The  base  of  the  great  wing  of  the  sphenoid  with  the  foramina  rotundum,  ovale,  and 
spinosum ;  over  the  glenoid  fossa  of  the  temporal  bone  (c) ;  the  tegmen  tympani  (d )  or  roof  of 
the  middle  ear  (see  page  59)  and  (very  important  from  a  practical  standpoint)  the  squamous  por- 


Foramen  caecum 
■    Foramen  caecum 
galli 

Crista  galli       . , 

>a  cnbrosa 

Cribriform  plate 


Lesser  wing  of  sphenoid 
Greater  wing  of  sphenoid 
Foramen  opticunfclis   superior 

Sphenoidal  fcsufft>ideus   ant 
Processus  clinoideus 

anterior    *  undum 
Foramen  rotundum      deus  p< 
Processus  clinoideus 
posterior 


Foramen  ovale 
Foramen  lacerum 
medium 

■ 

Squamous  portion 
of  temporal  bone 
Internal  auditory 

meatus 
Sulcus  petrosus 

superior 
Foramen  jugulare 


Posterior  condyloid 
foramen 


Mastoid  foramen 
Foramen  occipitale 


Internal  occipital  crest 


TOPOGRAPHIC    A 


PL  A  I  t  1. 

<cen  from  within.      i 
ranial  nerve; 

h.icf  veins  I 


!  mstration 

f 

a  should  also              rtco^t — — ^^^  vhich  are  aper- 

im  giving  pas        .•^rnous  a  ^^V             i  veins  of  the  head 
■ral  sinuses.     The/Mood  in  th<  \^                    rd,  so  that 
the  cercbraf  sinuses,  particuL  i  the  intracranialVjIood  pressure  is  in- 
ning n-wn.i^n1?  {hi/fu. fl       [                  In  of  blood  from  th     \                e  purpose 

■iiru^fcttawl  t/iiMt-       — "" ""         flj          *  1  the  ear  in  tl           \ 

|.  ,4^Uymi^h  tb/m   in  fiction — - — !  ied  from  the 


'■.■ 


and  other  in 
ish:  ,m„ijq*  inmate' 

Orboti    m„hnX"^imno4 

sinus  (^^fe^S 

foramen 

auditos|*rtr»««e$ — | <'  ■■'  ■ 1 — 


v  ombosis 


ooin.xj  ioonw*p8' 
Mod  UJoqmj)  )o 
r»>il.uK  iMiv.ml 

(■'•''.'■■  J!0tf)TM1  «Mtt&> 

i.  in-jqiM 
5ttUitii  OMUfcfl  ' 

l<ir.lYbfio«flM 
n 


mate 

.  foramina  are  subject  to  very  gi  \ 

-ide  of  the  sagittal  suturi  \  :  the 

longitudinal  sinus  and  may  bi        \       upon  one 

"  g  the  occipital  veins  wfth  the  lateral 

tery  to  the  dura  mater).     This 

two   ringer- breadths  beh  \  rnal 

[  all  the  emissary 


if  the  m 


51      foramen,  the 

)W  th  N 

■    .   . —     riion  of  tii  fins  of  the 

/ 
:  small  foramina  v. 

■ — .  the  torcular  1 

TT] .  '  i  the  foramina  for  th:  / 


but 

midtlli         1«9»  l«Jfcir>3o  ismaJ«I 


nurrit 


resencc  of 

They  are 

erior 

if  the  frontal  bone 

the  n  mial 

mdum,  ovale,  and 

1 )  or  roof  of 

the  squamous  por- 


Tab./. 


Foramen  caecum 
Crista  galli 
_  Lamina  cribrosa 


Ma  parva  oss.  sphen. 
Ala  magna  oss.  sphen 
l  Foramen  opticum 
&  Fissura  orbitalis  superior 
^..Processus  clinoideus  anterior 
Foramen  rotundum 
Processus  clinoideus  posterk 


...Foramen  ovale 
...Foramen  lacerum 


^•4-Squama  temporalis 


Porus  acusticus  internus 
Sulcus  petrosus  superior 
Foramen  jugulare 


//^Emissarium  condvloideum 
'  Emissarium  mastoideum 
Foramen  occipitale  magnum 


Crista  occipitalis  interna 


THE    CRANIUM.  23 

tion  of  the  temporal  bone  (b).  The  floor  of  the  sella  turcica  and  the  lateral  walls  of  the  body  of 
the  sphenoid  bone  should  also  be  mentioned  here,  as  they  are  thin  walls  of  the  large  sphenoidal 
sinuses  (/)  (see  page  52).  In  the  posterior  cranial  fossa  the  bone  is  thinnest  at  the  bottom  of  the 
fossa  (e).  The  osseous  layer  separating  the  lateral  sinus  from  the  mastoid  cells  is  often  very 
thin,  and  this  is  a  fact  of  great  practical  importance  (see  page  59). 

Particularly  strong  portions  of  the  base  are  to  be  found:  In  the  median  line:  the  crista  galli, 
the  clivus  [i.  e.,  the  body  of  the  sphenoid  between  the  dorsum  sellae  and  the  basilar  portion  of  the 
occipital. — Ed.],  the  internal  and  external  occipital  protuberances,  and  the  internal  and  external 
occipital  crests.  Laterally :  the  great  wing  of  the  sphenoid,  with  the  exception  of  its  base,  and 
the  anterior  and  middle  parts  of  the  petrous  portion  of  the  temporal  bone  with  the  cochlea  and 
labyrinth. 

From  the  preceding  statements  it  will  be  observed  that  the  middle  cerebral  fossa  is  relatively 
the  weakest  and  therefore  predisposed  to  fractures  which  often  involve  the  nerves  passing  along 
the  base  of  the  brain  in  this  situation  (see  page  32  and  Fig.  9).  If  the  thinness  of  the  orbital  roof 
is  appreciated  (see  Fig.  16),  it  will  be  readily  understood  how  easy  it  is  for  a  punctured  wound  to 
pass  the  eyeball,  perforate  the  roof  of  the  orbit,  and  penetrate  into  the  frontal  lobe  of  the  brain. 

Although  injuries  of  the  brain  are  generally  accompanied  by  injuries  of  the  surrounding 
bones,  a  study  of  the  base  of  the  cranium  shows  that  it  is  possible  for  a  fine-pointed  instrument 
to  enter  the  orbit,  pass  through  the  sphenoidal  fissure  or  the  optic  foramen,  and  injure  the  brain 
without  producing  a  fracture  of  the  bone. 

It  will  also  be  understood  that  fractures  of  the  cribriform  plate  of  the  ethmoid  (*.  e.,  the  nasal 
roof)  may  lead  to  hemorrhage  from  the  nose,  and  that  cerebrospinal  fluid  may  escape  through 
the  nose  if  the  membranes  of  the  brain  are  lacerated.  The  same  thing  may  occur  in  fractures  of 
the  middle  fossa,  where,  after  laceration  of  the  wall  of  the  sphenoidal  sinus  which  opens  into  the 
superior  meatus  of  the  nose  (see  page  53,  Fig.  11,  Fig.  19,  and  Plate  4),  there  is  not  only  an  escape 
of  cerebrospinal  fluid,  but  where  even  a  rapid  and  fatal  nasal  hemorrhage  has  been  observed 
from  a  rupture  of  the  internal  carotid  artery  which  lies  in  close  relation  with  the  wall  of  the  sinus 
(see  pages  31  and  34).  If  the  line  of  fracture  strikes  the  optic  foramen,  the  ophthalmic  artery 
may  give  rise  to  a  large  effusion  of  blood  into  the  orbit  [producing  a  subconjunctival  ecchymosis, 
more  rarely  exophthalmos. — Ed.].  The  escape  of  blood  or  cerebrospinal  fluid  from  the  ear 
presupposes  a  fracture  of  the  tegmen  tympani  and  a  laceration  of  the  drum-membrane  [the  blood 
coming  from  the  vessels  of  the  tympanum  or  from  one  of  the  neighboring  sinuses. — Ed.],  or  the 
blood  may  come  from  the  sigmoid  sinus,  reaching  the  middle  ear  by  way  of  the  air-cells  in  the 
mastoid  process  (see  page  31  and  Fig.  22).  In  this  case  blood  from  the  posterior  cranial  fossa 
may  escape  from  the  nose  or  mouth,  consequently  a  fracture  of  any  of  the  three  cranial  fossas  may 
cause  a  hemorrhage  from  the  nose,  for  it  must  be  remembered  that  with  an  intact  drum-membrane, 
the  blood  poured  out  into  the  middle  ear  may  reach  the  nasal  or  oral  cavity  through  the  Eustachian 
tube  and  escape  from  the  nose  or  mouth  (see  Plate  4  and  Fig.  19). 

[Cerebrospinal  fluid  escapes  from  the  ear  when,  in  addition  to  the  fracture  of  the  petrous  bone 
and  tear  of  the  tympanic  membrane,  there  has  occurred  a  rent  in  the  dura  and  arachnoid  or  their 
prolongations  into  the  internal  auditory  meatus  through  which  the  subarachnoid  space  com- 
municates with  the  tympanum.     A  serous  discharge  derived  from  the  mastoid  cells  or  consisting 


24  TOPOGRAPHIC    AND    APPLIED   ANATOMY. 

of  blood-serum  may  escape  through  a  torn  tympanic  membrane  after  injury  without  fracture; 
it  is,  however,  of  relatively  infrequent  occurrence  and  scanty. 

After  fracture  of  the  posterior  cranial  fossa  ecchymosis  is  sometimes  observed  in  the  posterior 
triangle  of  the  neck. 

Fractures  of  anterior  fossas  may  be  accompanied  by  disturbances  of  the  sense  of  smell, 
those  of  the  temporal  bone  by  disturbance  of  hearing  or  paralysis  of  the  facial  nerve. 

It  must  not  be  forgotten  that  in  the  comatose  or  very  young,  blood  from  the  nose  or  mouth 
may  be  swallowed  and  afterward  vomited  or  passed  at  stool. — Ed.] 

In  the  region  of  the  sella  turcica  there  is  only  a  relatively  thin  plate  of  bone  separating  the 
sphenoidal  sinus  from  the  cranial  cavity,  and  tumors  originating  in  this  sinus  may  encroach  upon 
the  cranial  cavity  and  lead  to  compression  of  the  brain  or  of  the  nerves  situated  at  its  base.  The 
same  is  true  of  tumors  proceeding  from  the  ethmoidal  cells,  since  these  spaces  are  separated 
from  the  cranial  cavity  only  by  a  thin  plate  of  the  frontal  bone  on  either  side  of  the  cribriform 
plate  (see  Fig.  16). 

THE  SCALP. 

The  greater  portion  of  the  skin  of  the  cranial  region  is  covered  with  hair  (see  Figs.  6  and  7) 
and  differs  in  many  respects  from  the  skin  in  other  portions  of  the  body.  It  is  not  only  specially 
rich  in  sebaceous  glands,  which  claim  the  attention  of  the  practitioner  as  the  starting-point  of 
many  cutaneous  diseases  as  well  as  of  sebaceous  cysts,  but  the  customary  layer  of  loose  sub- 
cutaneous tissue,  giving  the  skin  its  mobility,  is  absent  in  this  situation.  In  its  place  there  is 
present  a  firm  subcutaneous  stratum  infiltrated  with  fat,  which  is  directly  continuous  with  the 
subcutaneous  tissue  of  the  eyes  and  lids,  thus  explaining  the  readiness  with  which  erysipelas  of 
the  scalp  extends  to  these  parts.  This  subcutaneous  stratum,  together  with  the  overlying  skin 
(epidermis  and  corium)  and  the  underlying  occipitofrontal  aponeurosis,  forms  a  firm  layer, 
usually  spoken  of  as  the  "scalp,"  which  may  be  readily  torn  away  from  the  external  periosteum 
or  pericranium  before  opening  the  cranial  cavity.  The  scalp  is  bound  down  to  the  vault  of  the 
skull  by  such  a  very  loose  and  movable  connective  tissue,  the  subepicranial  tissue,  that  it  may  be 
readily  pushed  back  and  forth  with  the  hand,  or  even  by  voluntary  muscular  contractions  in  some 
individuals.  The  skin  and  the  occipitofrontalis  muscle,  the  tendinous  portion  of  which  bears  the 
name  galea  aponeurotica,  are  firmly  attached  to  each  other  by  tense  connective-tissue  fibers 
(retinacula)  which  pass  transversely  through  the  subcutaneous  stratum. 

The  occipitofrontalis  muscle  is  composed  of  a  muscular  and  of  a  tendinous  part.  The 
muscular  part  consists  of  an  anterior,  of  a  posterior,  and  of  a  lateral  portion.  The  anterior 
portion,  the  frontalis  (see  Plate  2),  arises  from  the  supraorbital  margin  and  the  skin  of  the  eye- 
brows; the  posterior  portion,  the  occipitalis,  takes  origin  from  the  superior  curved  line  of  the 
occiput;  the  lateral  portions  may  be  supposed  to  consist  of  the  rudimentary  attrahens,  attollens, 
and  retrahens  aurem,  which  are  attached  to  the  auricle.  The  tendinous  portion  is  firm  and  dense 
upon  the  vertex,  but  loses  these  characteristics  at  the  side  of  the  skull,  where  it  overlies  the  tem- 
poral fascia  and  is  attached  with  it  to  the  zygoma  or  is  continuous  with  the  parotid  and  masse- 
teric fascia  below. 

The  dense  subcutaneous  tissue  and  the  firm  connection  of  the  skin  with  the  aponeurosis  upon 


THE    SCALP. 


25 


the  one  hand,  and  the  laxity  of  the  subepicranial  tissues  upon  the  other,  are  responsible  for  the 
fact  that  cutaneous  wounds,  in  which  the  aponeurosis  is  not  divided,  do  not  gape,  in  contradis- 
tinction to  cutaneous  wounds  in  other  regions.  Gaping  occurs  only  when  the  aponeurosis,  and 
consequently  the  entire  thickness  of  the  scalp,  has  been  divided.  Wounds  at  right  angles  to  the 
direction  of  the  fibers  of  the  occipitofrontalis  gape  more  than  those  made  in  a  sagittal  direction. 
Owing  to  the  dense  connective  tissue  intimately  uniting  the  skin  and  galea  aponeurotica,  and  the 
consequent  loss  of  elasticity,  large  cutaneous  defects  cannot  be  covered,  since  it  is  impossible  to 
bring  the  edges  of  the  wound  together.  In  contrast  to  effusions  of  blood  in  the  loose  subepi- 
cranial tissue,  ecchymoses  in  the  dense  subcutaneous  tissue  are  not  very  extensive,  but  give  rise 
to  circumscribed  swellings. 


:  — —  Sebaceous  glands 

Corium 

Hair-follicle 

Subcutaneous  fatty  tissue 

;=i-Retinacula 


Artery 

Galea  aponeurotica 

Subepicranial  tissue 

Pericranium ^^B^H  ** — ""* 

External  plate —  ^ 

Internal  plate 

Dura  mater -; — 11  *T~"~ — - 

Fig.  6. — A  cross-section  of  the  layers  of  the  scalp  and  of  the  cranium. 


The  same  condition  of  affairs  is  noted  in  purulent  inflammations,  since  suppuration  in  the 
scalp  does  not  become  diffuse,  while  suppuration  beneath  the  scalp  may  continue  to  extend  until 
its  progress  is  arrested  at  the  supraorbital  margins,  the  zygoma,  and  the  superior  curved  line  of 
the  occiput.  In  such  cases  an  early  and  deep  incision  is  necessary,  since  spontaneous  perforation 
through  the  firm  and  dense  scalp  is  not  to  be  expected. 

The  scalp  is  more  liberally  supplied  with  blood  than  any  other  cutaneous  area.  In  this 
situation,  in  contrast  to  the  usual  relation,  large  vessels  are  found  in  the  subcutaneous  connective 
tissue.  These  arteries  are  so  firmly  imbedded  in  this  dense  tissue  that  it  is  quite  difficult  to  pick 
them  up  with  a  hemostat  after  division,  and  the  hemorrhage  must  frequently  be  arrested  by 
suture.  The  arterial  anastomoses  are  so  numerous  that  they  form  a  large-meshed  network  of 
arteries  which  is  spread  out  upon  the  galea  aponeurotica  (see  Plate  2).     Every  portion  of  the 


26  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE  2. 
The  external  muscles,  arteries,  veins,  and  nerves  of  the  face. 

scalp  is  supplied  with  blood  from  all  sides,  and  the  practical  application  is  that  even  very  large 
cutaneous  flaps  with  small  pedicles  will  readily  heal  when  replaced  in  their  proper  position. 
The  arteries  also  give  off  numerous  branches  to  the  cranium. 

The  arteries  of  the  scalp  (see  Plate  2)  originate  partly  from  the  internal,  but  chiefly  from 
the  external  carotid.  The  temporal  and  occipital  branches  are  so  large  that  in  rare  instances  they 
have  been  known  to  produce  a  fatal  hemorrhage. 

The  branches  of  the  external  carotid  artery  are : 

1.  The  superficial  temporal,  the  direct  upward  continuation  of  the  external  carotid.  It 
passes  upward  covered  by  the  parotid  gland  behind  the  ramus  of  the  jaw,  runs  over  the  zygoma, 
and,  at  a  varying  distance  (usually  about  one  centimeter)  above  the  zygoma,  divides  into  an 
anterior  or  frontal  branch  and  a  posterior  or  parietal  branch.  The  other  main  branches,  varying 
somewhat  in  their  point  of  origin,  are  the  transverse  facial  (passing  forward  beneath  the  zygoma 
and  upon  the  masseter  muscle)  and  a  smaller  artery,  the  orbital  (running  above  the  zygoma  to  the 
external  canthus  of  the  eye).  The  pulsation  of  the  temporal  artery  may  be  palpated  in  front  of 
the  tragus,  where  the  vessel  leaves  the  parotid  gland,  and  where  it  may  be  ligated. 

2.  The  occipital  artery,  one  of  the  two  posterior  branches  of  the  external  carotid,  passes 
backward  beneath  the  posterior  belly  of  the  digastric  muscle,  grooves  the  mastoid  portion  of  the 
temporal  bone  behind  the  mastoid  process  (this  groove  is  frequently  absent),  ascends  between 
the  muscles  of  the  neck,  pierces  the  fibrous  origin  of  the  trapezius  to  one  side  of  the  median  line 
[at  junction  inner  and  middle  thirds  of  superior  curved  line. — Ed.],  and  runs  upward  upon  the 
occipitofrontalis  muscle.  It  has  no  large  branches  bearing  special  names  which  are  distributed 
to  the  scalp.  If  the  mastoid  and  parietal  foramina  are  well  developed,  this  artery  gives  off  a 
mastoid  and  a  meningeal  branch  which  run  through  these  foramina  and  supply  the  dura  mater. 

3.  The  posterior  auricular  artery,  the  other  and  smaller  of  the  two  posterior  branches  of  the 
external  carotid,  runs  upward  in  front  of  the  mastoid  process  behind  the  ear  and  is  covered  by  the 
posterior  auricular  muscle. 

The  branches  furnished  by  the  internal  carotid  come  out  of  the  orbit  from  the  ophthalmic 
artery.  They  are  small  vessels  which  possess  additional  interest  from  their  anastomoses  with 
the  branches  of  the  external  carotid.     They  are: 

1.  The  frontal  artery,  passing  upward  through  the  frontal  notch  alongside  of  the  root  of  the 
nose. 

2.  The  supraorbital  artery,  external  to  the  preceding  vessel,  which  runs  through  the  supra- 
orbital notch  or  foramen  to  reach  the  skin  of  the  forehead. 

Veins. — Only  the  larger  venous  trunks  accompany  their  corresponding  arteries;  the  remain- 
ing venous  branches  form  a  large-meshed  network  upon  the  galea  aponeurotica.  They  acquire 
special  importance  from  their  connection  with  the  interior  of  the  cranial  cavity  through  the 
emissary  foramina  and  from  the  fact  that  they  receive  numerous  tributaries  from  the  cranium. 
We  observe: 

1.  The  frontal  vein,  frequently  single  (the  "vein  of  anger"),  which  is  found  in  the  frontal 


Parietal  branch  of 

temporal  artery 


Auricularis  su- 
perior muscle   , 
Temporal  artery 
Auriculotemporal  n 
Temporal  vein 
Posterior  auricular 

artery 
Occipitalis  muscle 

Occipitalis  major  nerve 

Occipital  artery 
Parotid  gland 

Sternocleidomastoid  muscle 

Trapezius  muscle 
Occipitalis  minor  nerve 

Splenius  muscle 
Auricularis  magnus  muscle 


rontal  artery  and  nerve  > 
Jr  rootalis  muscle 
Supraorbital  artery  and  nerve 
F  ronlal  vein 

ilal  branch  of  temporal  a. 


Orbicularis  .palpe- 
brarum 


Angular  artery 

M.   levator   labii 

superioris  ala-que 
n .    j 


Transverse  facial  artery 
KyKomaticus    cu> 
Parotid  duct 
( »rliiculari>  oris 
linuukilor  muscle 
Facial  artery 
Masseter  m. 


Depressor  labii  infcrioris  m. 
Depressor  anguli  oris 
Facial  vein 
Platysma  muscle 


TOP' 


PLA 

The  uscles,  ax; 


>f  the  face. 


p  is  supj> 

The  arli 

The  arteries  of  the  scaU  ^^  ^^-^^^ 

s^  ^s-  they 

/ 
/  behind  the  ramus  of  th< 

arte,  /  centimeter)  ab<> 


i  ansa  la*  natts  U.Wui  i , 

9VT»a  bflk  \lMwmmlk\ww& 

.*ls-mq<iv)l  to  rbaBtdil^gpi^. 

-scjIbq    aruslooi  li<> 

auncid 


2/  branch.     The  other  m*»i 

e  transverse  facial  (passing 
1  smaller  artery,  the  orbital  (runnin; 
.  he  pulsation  of  the  temporal  artery  ma 


croal  car 
\ 

es  in 

fcs,  va 


)tid  gland,  and  where  it  may  h< 
posterior  branches  of  the  extern;.  .  jhoA 

.  of  the  digastric  musf*1  .  I  porTI 


to  rfonr,-^ 
^unt  lui.«|rml 


IMlit  xslujuiA . 

tidal   ioi6/ail   .M 
oohaqDS 

iidel   in  ' 
aiioii-xlii-i 
auaiteiri'  >8tS 
lonim 

Xatu  Lsbtl 

Ijufi  tiiunc'l " 
sbeum  y>Uqmtt8- 

•mTmf1DTi 


_         — - — — -~ 




Milm.  1011*1 
LiaMMDtUulu^iiuA 


;in  of  : 


idle  thirr  /      fF 

* 

t  •-/ 

»  - 


■•)lwurn  ?.uirHq? 


mished  by  rotid  come  out  of 

.Email  ^____^__-         3  additional  interest  l 

They 

I  through  the  frontal  1 


tfJF^1 

nose. 

2.  T  N. 

orbital  n  .  ach  therein  of  1 

Veins.  venous  truflks 

venous  !  hed  nei  e  gal 

cial  im porta: 

y  foramina  ; 
observe: 
1.  The 


ii  the 
ie  cranium. 


Tab. 


Ramus  parietalis 
a.  temp. 


M.  auricul.  super, 
A.  temporalis. 
N.  auriculotemporalis 

V.  temporalis 

A.  auricularis  poster 

M.  occipitalis 


N.  occipitalis  major 


.N.  et  A.  frontalis 

•M.  frontalis 

N.  et  A.  supraorbitalis 

V.  frontalis 

Ramus  frontalis 
a.  temp. 


M.  orbicularis 
oculi 

\.  annularis 


A.  occipitalis 
Glandula  parotis 


sternocleidomastoi- 
deus 

M.  trapezius 
N.  occipitalis  minor 
M.  splenius 
N.  auricularis  magnus 


Cap.  annulare 

..Caput 

'  infraorbital e 

Caput 

z  ygomat  icum 

A.  transversa  facie 
M.  zygoroaticus 
Ductus  parotideus 
M.  orbicularis  oris 
M.  buccinator 
A.  maxillaris  ext. 
M.  masseter 

M.  quadratus  labii  infer 

M.  triangularis 

V.  facialis  anterior 

Platysma 


"2    = 


S« 


THE    SCALP.  27 

region  and  usually  empties  into  the  angular  vein.  [The  angular  vein  communicates  with  the 
ophthalmic  vein  and  through  it  with  the  cavernous  sinus ;  it  thus  favors  the  extension  of  infection 
from  the  face  or  orbit  to  the  interior,  particularly  in  erysipelas. — Ed.] 

2.  The  temporal  vein,  usually  situated  behind  the  artery  of  the  same  name.  It  unites  with 
the  internal  maxillary  to  form  the  temporomaxillary  vein. 

3.  The  posterior  auricular  vein,  draining  the  region  supplied  by  the  artery  of  the  same 
name.     It  assists  in  the  formation  of  the  external  jugular  vein. 

4.  The  occipital  vein,  which  empties  into  the  external  jugular  vein.  [It  generally  receives 
the  mastoid  emissary  vein,  one  of  its  tributaries  receives  the  parietal  emissary  vein  and  occasionally 
an  emissary  vein  from  the  torcular  Herophili  opens  into  it  (Cunningham). — Ed.] 

[The  veins  of  the  scalp  are  also,  through  the  diploic  veins,  connected  with  the  veins  of  the 
dura  mater  and  the  venous  sinuses.  Similar  connections  are  established  by  small  veins  which 
pass  from  the  pericranium  directly  through  the  bones,  and  particularly  through  the  inter- 
sutural  membranes. — Ed.] 

The  important  lymphatic  vessels,  through  which  inflammations  extend  to  the  scalp,  are 
situated : 

1.  Anteriorly  in  the  middle  line  of  the  forehead  passing  down  alongside  of  the  nose  to  the 
lymphatic  vessels  of  the  face  and  to  the  submaxillary  lymphatic  glands. 

2.  Laterally  along  the  temporal  and  posterior  auricular  arteries  and  passing  to  the  lymphatic 
glands  of  the  parotid  region  and  to  those  behind  the  ear.  (This  lymphatic  vessel  is  particularly 
affected  by  syphilis.) 

3.  Posteriorly  along  the  occipital  artery  and  running  to  the  occipital  lymphatic  glands  upon 
the  origin  of  the  trapezius. 

There  are  no  lymphatic  glands  upon  the  cranial  vault. 

Nerves  (Plate  2). — Only  the  sensory  nerves  of  the  scalp  are  of  interest  to  the  practi- 
tioner (the  motor  filaments  to  the  occipitofrontalis  muscle  are  supplied  by  the  facial  nerve). 
They  are  furnished  partly  by  the  trifacial  and  partly  by  the  cervical  nerves.  The  following 
distinct  branches  should  be  mentioned : 

1.  The  supratrochlear  (a  branch  of  the  frontal  from  the  ophthalmic  division  of  the  fifth)  is 
found  above  the  inner  canthus  of  the  eye,  one  centimeter  from  the  median  line  at  the  supraorbital 
margin,  where  it  leaves  the  orbit  to  reach  the  skin  of  the  forehead. 

2.  The  supraorbital  nerve  (also  a  branch  of  the  frontal  from  the  ophthalmic)  is  larger  than 
the  preceding  and  frequently  divides  into  two  branches  as  it  runs  over  the  supraorbital  margin. 
It  passes  upward  through  the  supraorbital  joramen  or  notch,  which  is  palpable  2.5  centimeters 
from  the  median  line  [at  junction  of  inner  and  middle  thirds  of  upper  margin  of  the  orbit. — Ed.], 
and  which  is  the  landmark  for  locating  the  nerve  in  supraorbital  neuralgia.  In  performing 
neurectomy  upon  this  nerve  the  orbit  is  entered  from  the  supraorbital  margin,  the  orbital  contents 
are  pushed  downward,  and  the  nerve  is  sought  as  far  back  as  possible  immediately  below  the 
orbital  periosteum  (the  so-called  "periorbita")  upon  the  levator  palpebral  superioris  muscle. 
In  this  manner  a  long  piece  of  the  nerve  may  be  excised. 

3.  The  auriculotemporal  nerve  (from  the  inferior  maxillary  division  of  the  trifacial)  accom- 
panying the  temporal  artery,  frequently  being  situated  between  this  vessel  and  the  vein,  and 
passing  to  the  skin  of  the  temporal  region. 


28  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

Fig.  7. — The  layers  of  the  scalp,  the  cranium,  and  the  membranes  of  the  brain. 

Fig.  8. — The  sinuses  of  the  dura  mater.  The  calvarium  has  been  removed  with  the  exception  of  a  central 
arch  of  bone,  so  that  the  processes  of  the  dura  mater  have  been  left  intact. 

4.  The  occipitalis  minor  nerve  from  the  cervical  plexus,  and 

5.  The  occipitalis  major,  the  nerve  of  cervical  neuralgia,  not  a  branch  of  the  cervical  plexus 
but  a  dorsal  branch  of  the  second  cervical  nerve.  It  usually  perforates  the  fibrous  origin  of  the 
trapezius  in  company  with  the  occipital  artery  and  immediately  divides  into  several  branches 
which  ascend  to  the  vertex. 

The  exposure  of  the  nerve  is  difficult,  as  it  is  imbedded  in  dense  connective  tissue  and  the 
pulsations  of  the  occipital  artery,  the  most  frequently  recommended  guide,  are  often  not  dis- 
tinctly palpable. 

The  external  periosteum  of  the  skull,  the  pericranium,  is  relatively  thin  in  comparison  with 
the  internal  periosteum  (dura  mater).  It  is  very  vascular  and  is  not  closely  attached  to  the  bones 
except  at  the  sutures,  where  it  becomes  continuous  with  the  outer  layer  of  the  dura  mater  constitut- 
ing the  inter-sutural  membrane.  During  childhood  the  pericranium  lies  loosely  upon  the  skull- 
cap, and  in  cephalhematoma  neonatorum  it  is  frequently  stripped  up  from  the  bones  (particu- 
larly from  the  parietal)  as  far  as  the  surrounding  sutures. 

In  flap-like  wounds  of  the  scalp  the  pericranium  is  easily  stripped  up  from  the  bone  [except 
at  the  sutures,  where  it  is  firmly  attached. — Ed.]  in  association  with  the  overlying  tissues.  It 
receives  its  blood-supply  chiefly  from  the  vessels  of  the  scalp,  but  a  portion  of  it  is  also  furnished 
by  the  perforating  branches  of  the  lateral  or  endosteal  layer  of  the  dura  mater  (see  page  29).  [The 
pericranium  differs  from  the  periosteum  of  other  bones  in  that  it  may  be  removed  for  a  consider- 
able area  without  producing  necrosis,  due  to  the  fact  that  the  cranial  bones  are  in  large  part 
nourished  by  vessels  from  the  outer  layer  of  the  dura. — Ed.] 

THE  MEMBRANES  OF  THE  BRAIN. 

The  dura  mater  is  of  twofold  importance:  (1)  For  the  skull;  (2)  for  the  brain. 

1.  The  dura  mater  forms  the  internal  periosteum  of  the  cranium.  Since  it  is  responsible  for 
the  growth  in  thickness  of  the  bone,  we  find  it  intimately  adherent  to  the  cranial  vault  during 
childhood,  while  in  the  adult  after  this  growth  is  completed,  the  cranial  cavity  may  be  opened  and 
the  calvarium  removed,  leaving  the  dura  mater  and  the  underlying  brain  intact.  Even  then, 
however,  the  numerous  vessels  passing  from  the  dura  into  the  bones  are  torn  across.  In  general 
the  dura  is  more  intimately  attached  to  the  base  than  to  the  cranial  vault,  the  adhesion  being  most 
firm  at  the  cribriform  plate  of  the  ethmoid,  the  sella  turcica,  the  clivus,  and  the  petrous  portion  of 
the  temporal  bone  [which  in  part  explains  the  infrequency  of  extra-dural  collections  of  blood 
and  pus  at  these  situations. — Ed.].  If  the  excised  dura  is  placed  in  water,  numerous  vessels  are 
seen  upon  its  outer  surface,  while  the  inner  surface  seems  smooth  and  contains  only  capillary 
ramifications.  It  is  a  fact  that  no  vessels  pass  from  the  dura  to  the  brain.  It  is  completely 
separated  from  the  underlying  pia  mater  by  the  subdural  space,  which  is  filled  with  lymph.  The 
importance  of  the  dura  as  a  periosteal  layer  is  also  distinctly  demonstrated  by  the  occasional 
ossification  of  this  structure.     [By  most  authorities  the  dura  mater  is  said  to  consist  of  two  layers, 


F'g-  7- 


Dura  maler 

Pia  mater  and 
arachnoid 

Cranium 
Pericranium 
Subepicranial  connec- 
tive tissue 
Oocipitofiontalis   muscle 
Subcutaneous  layer 


Fie.  8. 


Right  superior  petrosal  sinus 

Sinus  alae  parvae 

Edge  of  the  tentorium 

Internal  carotid  artery 

Righior  infer,  pe'.rosal  sinus 

Circular  sinus 

Cavernous  sinus 


Falx  cerebri 


Superior  longitudinal  sinus 
Inferior  longitudinal  sinus 

Cerebral  veins 

Straight  sinus 
Right  literal  sinus 
Internal  auditory  meatus 

Jugular  foramen 

Left  lateral  sinus 

Occipital  sinus 

Left  superior  petrosal  sinus 


THE    MEMBRANES    OF    THE    BRAIN.  29 

an  outer — endosteal — which  forms  the  internal  periosteum  of  the  bones,  and  an  inner  which  sends 
off  the  dural  processes,  falx  cerebri,  etc.     Between  the  two  layers  the  sinuses  are  placed. — Ed.] 

[The  dura  mater  is  continuous  through  the  optic  foramen  with  the  periosteum  of  the  orbit, 
through  the  foramen  magnum  with  the  dura  of  the  cord,  and  through  the  various  other  foramina 
at  the  base  of  the  skull  where  nerves  enter  or  emerge  it  sends  processes.  These  facts,  together 
with  its  intimate  attachment  to  the  cranial  bones,  explain  the  frequency  of  dural  involvement 
secondary  to  external  infections. — Ed.] 

Although  some  of  its  blood-supply  is  derived  from  the  anterior,  posterior,  and  small  menin- 
geal, and  occasionally  from  a  relatively  large  mastoid  branch  of  the  occipital,  these  are  small 
and  practically  insignificant,  and  the  most  important  artery  of  the  dura  mater  is  the  middle 
meningeal  (see  Figs.  1, 10),  which  comes  from  the  internal  maxillary,  one  of  the  terminal  divisions 
of  the  external  carotid.  It  enters  the  cranial  cavity  through  the  foramen  spinosum,  runs  forward 
and  upward  along  the  great  wing  of  the  sphenoid  near  the  squamosphenoidal  suture,  and,  at  a 
varying  distance  from  its  point  of  entrance,  while  still  in  the  basal  region,  divides  into  an  anterior 
and  a  posterior  branch  (see  Fig.  1).  The  former  ascends  just  behind  the  coronal  suture  to  the 
posterior  frontal  region  [accompanied  sometimes  by  the  sphenoparietal  sinus,  which  may  be 
wounded  either  by  the  accident  which  has  compelled  manipulations  here  or  by  the  manipulations. 
— Ed.];  the  latter  runs  in  an  arched  course  almost  directly  backward  over  the  squamous  portion 
of  the  temporal  bone,  giving  off  ascending  branches  which  rest  upon  the  internal  surface  of  the 
parietal  bone.  The  middle  meningeal  artery  and  its  ramifications  are  lodged  in  furrows  upon  the 
inner  surface  of  the  cranial  vault  (see  page  18).  There  is  a  rich  anastomosis  between  the  branches 
of  the  artery.     The  vessel  also  gives  off  perforating  branches  to  the  scalp. 

Injuries  0}  the  middle  meningeal  artery  complicating  fractures  of  the  skull  are  justly  feared. 
Not  only  may  there  be  considerable  external  hemorrhage,  but,  what  is  much  more  likely,  the  blood 
may  be  poured  out  between  the  dura  and  the  bone,  into  the  subdural  space,  and,  if  the  arachnoid  is 
also  injured,  into  the  subarachnoid  space.  In  this  manner  there  is  produced  a  large  hematoma 
with  pronounced  symptoms  of  cerebral  compression  which  demand  operative  interference, — 
trephining  or  chiseling  open  the  skull,  turning  out  the  blood-clot,  and  ligation  of  the  artery.  As 
the  trunk  of  the  artery  is  situated  at  the  base  of  the  skull  and  is  reached  only  with  great  difficulty, 
we  are  specially  interested  in  the  exposure  of  the  regions  supplied  by  the  two  branches,  and 
particularly  in  the  exposure  of  the  anterior  branch,  the  one  most  frequently  involved.  Both 
branches  are  found  by  means  of  the  line  of  Kronlein  (see  page  37  and  Fig.  13),  which  is  drawn 
backward  from  the  supraorbital  margin  parallel  with  the  zygoma.  The  anterior  trephine  opening 
is  then  indicated  by  a  point  two  fingerbreadths  in  front  of  the  intersection  of  this  line  with  a  line 
drawn  at  right  angles  to  it  through  the  external  auditory  meatus;  the  posterior  opening  should 
be  made  two  fingerbreadths  behind  the  point  of  intersection.  The  posterior  branch  may  also 
be  exposed  two  centimeters  directly  above  the  external  auditory  meatus.  The  lateral  anastomoses 
of  the  vessels  make  it  necessary  to  apply  a  double  ligature  to  the  main  branch  affected.  [The 
line  of  Kronlein  referred  to  by  the  author  is  drawn  horizontally  backward  from  the  supraorbital 
margin  parallel  to  the  line  from  the  infraorbital  margin  through  the  external  auditory  meatus 
known  to  English  readers  as  Reid's  base  line.  To  expose  the  anterior  branch  of  the  middle  men- 
ingeal the  trephine  may  be  applied  on  the  line  of  Kronlein  from  i\  to  i£  inches,  depending  on 


30  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

the  size  of  the  head,  behind  the  external  angular  process.  The  posterior  branch  is  exposed  by 
making  an  opening  on  the  same  line  where  it  is  bisected  by  a  vertical  line  from  the  posterior 
border  of  the  mastoid  process.  It  must  not  be  forgotten  that  a  trephine  opening  which  has 
failed  to  exactly  locate  a  given  structure  may  be  easily  enlarged  and  thereby  rendered  effective 
by  the  use  of  the  rongeur. — Ed.] 

2.  The  dura  mater  serves  the  brain  as  a  supporting  and  protective  envelope.  From  its 
inner  layer  it  sends  partitions  or  processes  between  certain  of  the  brain  divisions.  These  are: 
(i)  The  jalx  cerebri  (Figs.  8, 9, 12,  and  16),  which  separates  the  cerebral  hemispheres  and  extends 
from  the  crista  galli  to  the  internal  occipital  protuberance  and  the  upper  surface  of  the  tento- 
rium cerebelli.  (2)  The  tentorium  cerebelli  (see  Fig.  17),  which  separates  the  occipital  lobes  of  the 
cerebrum  from  the  upper  surface  of  the  cerebellum  and  is  adherent  to  the  superior  margin  of  the 
petrous  portion  of  the  temporal  bone,  continuing  as  far  forward  as  the  anterior  and  posterior 
clinoid  processes  of  the  sphenoid  bone.  Its  posterior  attachment  corresponds  to  the  course  of  the 
lateral  sinus.  If  it  is  desired  to  remove  the  cerebellum  together  with  the  cerebrum,  the  insertion 
of  the  tentorium  at  the  petrous  portion  of  the  temporal  bone  must  be  previously  divided,  since  the 
cerebellum  cannot  pass  through  the  opening  which  transmits  the  cerebral  peduncles  (see  Fig.  17). 
(3)  The  jalx  cerebelli,  a  process  of  dura  mater  which,  varying  somewhat  in  its  formation,  runs  along 
the  internal  occipital  crest  corresponding  to  the  fissure  between  the  cerebellar  hemispheres  (see 
Fig.  12).  The  sella  turcica  and  the  contained  hypophysis  cerebri  are  covered  by  a  portion  of 
dura  mater  known  as  the  diaphragma  settee,  which  is  perforated  by  the  infundibulum. 
This  infundibulum  is  easily  torn  in  removing  the  brain. 

The  dura  mater  is  of  additional  importance  to  the  brain  since  it  receives  the  return  blood, 
which  is  collected  in  the  venous  sinuses  and  conducted  to  the  jugular  foramen.  The  sinuses  are 
more  or  less  rigid  canals  situated  in  the  dura  between  its  outer  and  inner  layers.  They  are  lined 
by  a  prolongation  of  the  lining  membrane  of  the  veins,  are  destitute  of  valves,  and  do  not  collapse 
when  injured.  Such  injuries  easily  occur  with  injuries  to  the  cranium;  but  they  are  relatively 
free  from  danger,  since  the  hemorrhage  is  easily  checked  and  cases  are  exceptional  in  which  air 
gains  access  to  the  vascular  system  from  an  opened  sinus.  A  more  dangerous  injury  is  the  com- 
plete internal  perforation  of  a  sinus  with  effusion  of  blood  into  the  subdural  space  and  the  symp- 
toms of  cerebral  compression.  In  trephining,  care  is  of  course  taken  to  avoid  the  sinuses.  From 
a  practical  standpoint  the  following  three  sinuses  are  the  most  important : 

1 .  The  superior  longitudinal  sinus,  holding  the  most  exposed  position  along  the  insertion  of 
the  falx  cerebri  (see  Figs.  8  and  12).  At  the  internal  occipital  protuberance,  the  location  of  the 
torcular  Herophili,  it  unites  with  the  lateral,  the  occipital,  and  the  straight  sinuses.  [This  sinus 
increases  rapidly  in  size  from  before  backward.  It  receives  veins  from  the  scalp  through  the 
parietal  foramina,  from  the  diploe,  the  dura  mater,  and  the  hemispheres  of  the  cerebrum.  Those 
from  the  cerebrum  run  into  the  sinus  from  behind  forward  opposite  to  the  direction  of  the  blood- 
current,  piercing  the  sinus  wall  very  obliquely  (Deaver).  Its  position  is  indicated  by  a  line 
drawn  over  the  median  line  of  the  vertex  from  the  root  of  the  nose  to  the  external  occipital 
protuberance. — Ed.] 

2.  The  lateral  sinus,  the  median  portion  of  which  is  called  the  sigmoid  sinus,  is  situated  in 
a  furrow  in  the  bone  (see  Figs.  9  and  22).     This  furrow  is  very  often  particularly  deep  upon  the 


THE    MEMBRANES    OF    THE    BRAIN.  31 

right  side.  The  fact  that  it  is  frequently  separated  from  the  mastoid  cells  by  only  a  thin  plate 
of  bone  (see  page  59)  is  of  great  practical  importance,  since  the  sinus  not  infrequently  becomes 
involved  (sinus  thrombosis)  from  suppuration  extending  into  the  mastoid  cells  from  the  middle 
ear.  The  external  guide  for  the  sinus  is  a  point  on  the  mastoid  process,  two  centimeters  behind 
the  posterior  margin  of  the  external  auditory  meatus.  The  posterior  border  of  the  mastoid 
process  is  frequently  employed  as  a  landmark,  but  it  cannot  be  utilized  in  all  cases,  as  the  varying 
size  of  the  bony  prominence  and  its  digastric  groove  of  inconstant  depth  may  give  rise  to  error. 
It  may  cause  the  operator  to  go  too  far  forward  and  consequently  to  strike  the  petrous  portion  of 
the  temporal  bone.  [The  term  "lateral  sinus"  should  be  restricted  to  that  portion  of  the  sinus 
between  the  external  occipital  protuberance  and  the  posterior  inferior  angle  of  the  parietal  bone ; 
the  remainder  of  the  sinus,  to  the  jugular  foramen,  is  known  from  its  tortuous  course  as  the 
sigmoid  sinus.  According  to  Wolsey,  the  genu  of  the  sigmoid  sinus — the  part  most  frequently 
involved  in  middle-ear  inflammations — is  convex  forward,  reaches  to  a  point  \  to  \  of  an  inch 
behind  a  coronal  plane  through  the  posterior  border  of  the  external  osseous  meatus,  and  is  on 
the  level  of  the  upper  part  of  the  meatus.  An  opening  may  be  made  into  the  genu  at  a  point 
half  an  inch  behind  the  posterior  wall  of  the  bony  meatus  between  the  levels  of  its  roof  and 
floor,  where  the  more  superficial  part  of  the  sinus  is  within  \  or  even  \  of  an  inch  of  the  surface 
and  is  therefore  placed  much  less  deeply  than  the  antrum. — Ed.] 

3.  The  third  of  the  most  important  sinuses  is  the  cavernous  sinus,  situated  to  either 
side  of  the  body  of  the  sphenoid  bone  [continuous  with  the  ophthalmic  veins  in  front,  dividing 
into  superior  and  inferior  petrosal  sinuses  behind,  and  communicating  by  means  of  the 
circular  sinus. — Ed.].  It  gains  additional  interest  since  it  surrounds  the  internal  carotid  artery. 
As  it  is  separated  by  only  a  very  thin  plate  of  bone  from  the  sphenoidal  air-cells  communicating 
with  the  nasal  cavity  (see  Fig.  11  and  page  53),  we  can  understand  why  fatal  hemorrhage  from 
the  nose  has  been  observed  as  the  result  of  rupture  0}  the  sinus  and  carotid  artery  after  fractures 
of  the  base  of  the  skull.  An  injury  to  the  carotid  artery  in  the  sinus,  which  is  also  possible  from 
a  penetrating  wound  through  the  sphenoidal  fissure,  may  lead  to  the  formation  of  an  arterio- 
venous aneurysm  and  to  a  subsequent  stasis  in  the  superior  ophthalmic  vein  of  the  orbit  (see 
page  46)  which  empties  into  the  sinus  through  the  sphenoidal  fissure.  This  symptom,  known  as 
pulsating  exophtlialmos,  is  due  to  the  fact  that  the  pulsations  of  the  carotid  artery  are  trans- 
mitted to  the  engorged  venous  spaces  and  displace  the  eyeball  anteriorly. 

[Cavernous  sinus  thrombosis  most  frequently  follows  inflammatory  affections  of  face  or 
upper  lip,  the  extension  taking  place  through  facial,  nasal,  and  ophthalmic  veins.  Thrombosis 
also  occurs — but  less  frequently— through  the  supraorbital  or  frontal  veins,  through  the  spheno- 
parietal sinus,  and  from  the  pterygomaxillary  region  through  the  vein  of  Vesalius.  This 
sinus  is  placed  between  the  two  layers  of  dura  mater,  is  intimately  related  to  the  Gasserian 
ganglion,  and  may,  during  operations  on  the  latter,  become  a  source  of  some  danger  and  great 
annoyance  from  bleeding,  sometimes  preventing  the  completion  of  the  operation. — Ed.] 

The  other  sinuses  are :  The  inferior  longitudinal  sinus,  in  the  concave  lower  margin  of  the 
falx  cerebri;  the  straight  sinus,  at  the  attachment  of  the  falx  cerebri  to  the  tentorium;  the  superior 
and  inferior  petrosal  sinuses,  along  the  superior  and  posterior  borders  of  the  petrous  portion  of 
the  temporal  bone  respectively;   the  circular  sinus,  composed  of  the  two  transverse  venous  con- 


32  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

Fig.  9. — The  base  of  the  skull  with  the  cranial  nerves,  as  seen  after  the  removal  of  the  brain.  Upon  the  left  side 
the  dura  mater  has  been  left  in  place  and  the  tentorium  cerebelli  incised  so  that  it  is  possible  to  look  into  the  posterior 
cerebral  fossa.  Upon  the  right  side  the  dura  has  been  removed  and  the  places  of  exit  of  the  nerves  are  visible  at  the 
base  of  the  skull. 

nections  between  the  cavernous  sinuses;  the  sphenoparietal  sinus  (sinus  alae  parvae),  running 
along  the  lesser  wing  of  the  sphenoid,  ascending  behind  the  coronal  suture  with  the  anterior 
branch  of  the  middle  meningeal  artery,  and  occasionally  imbedded  in  a  very  deep  bony  groove, 
to  reach  the  superior  longitudinal  sinus;  and  the  occipital  sinus,  in  the  attached  border  of  the 
falx  cerebelli. 

In  addition  to  the  cerebral  veins,  the  sinuses  also  receive  the  diploic  veins,  the  internal 
auditory  veins  from  the  internal  auditory  meatus,  the  meningeal  veins,  the  superior  ophthalmic 
veins,  and  the  emissary  veins  (see  page  22). 

Nerves. — After  the  removal  of  the  brain,  which  is  necessarily  preceded  by  a  division  of  the 
cranial  nerves,  the  latter  structures  may  be  observed  while  they  are  still  within  the  dura  mater 
at  the  base  of  the  skull  (see  Fig.  9).  A  number  of  them,  the  optic,  the  facial,  and  the  auditory 
nerves,  for  example,  disappear  at  the  same  place  at  which  they  leave  the  cranial  cavity.  Others, 
however,  pass  into  or  through  the  dura  and  pursue  an  intradural  or  a  subdural  course  for  a  vary- 
ing distance  before  they  leave  the  skull.  This  is  particularly  the  case  with  the  nerves  in  the 
middle  cranial  fossa,  which  on  account  of  their  course  are  therefore  most  likely  to  be  affected  by 
fractures  of  the  base  (see  page  23).  The  oculomotor  and  the  abducent  nerves,  for  example,  per- 
forate the  dura  at  the  anterior  extremity  of  the  tentorium,  but  do  not  leave  the  cranial  cavity  until 
they  reach  the  sphenoidal  fissure.  The  abducent  nerve  perforates  the  dura  upon  the  clivus,  but 
does  not  leave  the  skull  until  it  reaches  the  sphenoidal  fissure,  consequently  having  the  longest 
subdural  course  of  any  of  the  cranial  nerves.  The  trunk  of  the  trifacial  nerve  disappears  beneath 
the  edge  of  the  tentorium  in  the  posterior  cranial  fossa  and  forms  the  semilunar  ganglion,  which 
is  lodged  in  a  depression  near  the  apex  of  the  petrous  portion  of  the  temporal  bone  in  the  middle 
cranial  fossa.  This  ganglion  is  covered  by  the  dura  mater,  and  the  three  branches  of  the  tri- 
facial cannot  be  dissected  until  the  dura  has  been  removed  (see  Figs.  9  and  10).  When  very 
obstinate  trifacial  neuralgia  makes  it  necessary  to  attack  the  ganglion  through  the  temporal 
region,  carefully  elevating  the  temporal  lobes  of  the  cerebrum,  the  structures  most  endangered, 
in  addition  to  the  middle  meningeal  artery  (which  may  be  ligated),  are  the  cavernous  sinus  and 
the  carotid  artery.  The  extirpation  of  the  ganglion  is  followed  not  only  by  sensory  changes,  but 
also  by  a  unilateral  paralysis  of  the  muscles  of  mastication,  since  the  small  motor  root  in  intimate 
relation  with  the  ganglion  is  also  removed.  Unpleasant  symptoms  of  cerebral  compression  are 
not  infrequently  observed  after  the  operation. 

The  relations  of  the  nerves  in  the  middle  cranial  fossa  to  the  cavernous  sinus  and  to  the 
internal  carotid  artery  are  best  shown  by  a  frontal  section  (see  Fig.  11). 

The  abducent  nerve  lies  upon  the  internal  carotid  within  the  sinus,  while  the  illustration 
distinctly  shows  the  oculomotor,  the  trochlear,  and  the  first  and  second  divisions  (ophthalmic  and 
superior  maxillary)  of  the  trifacial  within  the  wall  of  the  sinus. 

Fractures  or  caries  of  the  base  of  the  skull  may  involve  one  or  more  of  the  cranial  nerves,  and 
the  symptoms  produced  by  the  affected  nerve  may  furnish  conclusions  as  to  the  site  of  the  lesion. 


Fig.  9. 


Facial  nerve 

Auditory  nerve 

Glossopharyngeal  nerve 

Pneumogastric  nerve 

Hypoglossal  nerve 

Spinal  accessory  nerve 
Cut  surface  of  the 
tentorium  cerebelli 


Tentorium  cerebelli 


ft. Orbital  plate  of  frontal  bone 

Cribriform  plate  of  ethmoid 


-  Lesserwingofthesphenoid 
bone 

Great  wing  of  the  sphenoid  bone 
.  Trochlear  nerve 

Ophthalmic  nerve 

—  Oculomotor  nerve 
l'"~~ Superior  maxillary  nerve 
Abducent  nerve 
Semilunar  ganglion 
Inferior  maxillary  nerve 

Squamous  portion  of 

temporal  bone 
Internal  auditory  meatus 

Anterior  condyloid  foramen 
Jugular  foramen 


Parietal  bone 

—  Groove  for  lateral  sinus 
Straight  sinus 


Falx  cerebelli 

Lateral  sinus 
Torcular  Herophili 
Occipital  bone 


THE    MEMBRANES    OF    THE   BRAIN.  33 

The  nerves  most  apt  to  give  rise  to  symptoms  are  the  facial  (paralysis  of  the  muscles  of  expression) 
and  the  auditory  in  fracture  or  caries  of  the  petrous  portion  of  the  temporal  bone,  the  abducent 
and  the  oculomotor,  and  more  rarely  the  trochlear,  the  trifacial,  and  the  optic.  Tumors  situated 
at  the  base  of  the  skull  may  press  upon  the  nerves  having  a  subdural  or  an  intradural  course  and 
consequently  lead  to  more  or  less  severe  pressure-symptoms  dependent  upon  the  particular  nerve 
affected. 

Under  certain  circumstances  olfactory  or  visual  disturbances  may  point  to  the  presence  of 
a  tumor  in  the  anterior  cranial  fossa;  symptoms  of  pressure  upon  the  semilunar  ganglion  and 
disturbances  of  the  muscles  of  the  eye  may  likewise  indicate  a  growth  in  the  middle  cranial  fossa. 
If  the  trunk  of  the  trifacial  is  pressed  upon  before  it  perforates  the  dura,  and  if  the  facial  and 
hypoglossal  nerves  are  compressed  at  the  base  of  the  skull,  we  are  justified  in  locating  the  lesion 
in  the  posterior  cranial  fossa,  while  symptoms  pointing  to  the  pons  or  cerebellum  would  demand 
the  same  localization.  Since  the  division  of  the  fifth  cranial  nerve  into  its  three  branches  takes 
place  within  the  cranial  cavity,  any  one  of  these  branches  may  be  affected  by  diseases  of  the  inner 
surface  of  the  base  of  the  skull. 

The  arachnoid  membrane  (the  second  of  the  brain  membranes)  (see  Fig.  7)  is  separated 
from  the  dura  by  the  subdural  space.  The  pia  mater  is  separated  from  the  arachnoid  by  the 
subarachnoid  space  which  is  filled  with  the  cerebrospinal  fluid.  Numerous  trabecular  pass  across 
this  subarachnoid  space  and  form  an  intimate  connection  between  the  arachnoid  and  pia,  par- 
ticularly at  the  convexities  of  the  cerebral  convolutions.  While  the  non-vascular  arachnoid 
bridges  over  the  sulci  between  the  convolutions,  the  pia  mater  carrying  the  ramifications  of 
the  blood-vessels  dips  into  the  sulci  and  is  intimately  attached  to  all  portions  of  the  surface 
of  the  brain.  In  several  places,  particularly  at  the  base  of  the  brain,  there  are  comparatively 
large  spaces  between  the  arachnoid  and  the  pia,  and  these  are  known  as  the  cisternce  sub- 
arachnoideales.  There  is  no  communication  between  the  subdural  and  the  subarachnoid  space, 
but  the  subarachnoid  space  freely  communicates  with  the  ventricles  of  the  brain  [through 
an  opening  in  the  roof  of  the  fourth  ventricle,  and  also  at  the  extremity  of  the  descending  horn 
of  the  lateral  ventricle. — Ed.]. 

It  consequently  follows  that  the  cerebrospinal  fluid  in  the  ventricles  may  be  drawn  off  after 
the  subarachnoid  space  has  been  opened. 

The  arachnoid  membrane,  particularly  in  the  vicinity  of  the  superior  longitudinal  sinus, 
possesses  variously  formed  villi,  groups  of  which  may  be  seen  projecting  into  the  interior  of  the 
sinus  or  its  lateral  recesses  when  this  venous  channel  has  been  laid  open.  They  act  as  normal 
places  of  drainage  for  the  cerebrospinal  fluid.  When  they  become  hypertrophied  they  form  the 
Pacchionian  bodies,  which  are  lodged  in  the  Pacchionian  depressions  (see  page  18). 

The  larger  branches  of  the  cerebral  vessels  are  found  in  the  subarachnoid  space.  Effusions 
of  blood  in  this  space  come  either  from  the  cerebral  vessels  or  from  the  vessels  of  the  dura,  in  which 
latter  case,  a  rupture  of  the  arachnoid  must,  of  course,  have  taken  place  (see  page  29).  The 
relation  of  the  arteries  to  definite  portions  of  the  base  and  to  definite  cranial  nerves  (see  Plate  3) 
makes  it  clear  that  aneurysm  of  these  arteries  must  produce  definite  localizing  symptoms  of  cere- 
bral compression. 

The  arterial  supply  of  the  brain  is  furnished  by  the  vertebral  and  internal  carotid  arteries 

3 


34  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  io. — The  Gasserian  ganglion  (ganglion  semilunare)  which  has  been  exposed  in  the  middle  cerebral  fossa  by 
the  removal  of  the  dura  mater. 

Fig.  ii. — Frontal  section  in  the  region  of  the  cavernous  sinus. 

which  form  the  circle  of  Willis,  situated  in  the  subarachnoidean  space  at  the  base  of  the  brain  in 
the  region  of  the  interpeduncular  space  (see  Plate  3). 

The  vertebral  artery,  soon  after  its  origin  from  the  subclavian  (see  Fig.  27),  enters  the  foramen 
in  the  transverse  process  of  the  sixth  cervical  vertebra,  passes  through  the  transverse  processes  of 
all  of  the  overlying  cervical  vertebras,  runs  toward  the  median  line  in  the  groove  upon  the  upper 
surface  of  the  posterior  arch  of  the  atlas,  perforates  the  posterior  occipito-atlantal  ligament  and 
the  dura,  and  reaches  the  anterior  surface  of  the  medulla  oblongata,  at  the  superior  boundary  of 
which  it  unites  with  the  vessel  of  the  opposite  side  to  form  the  basilar  artery.  This  artery  lies  in 
the  basilar  groove  of  the  pons,  and  at  its  superior  margin  divides  into  two  terminal  branches,  the 
posterior  cerebral  arteries. 

The  internal  carotid  artery,  commencing  at  the  bifurcation  of  the  common  carotid  at  the 
level  of  the  upper  margin  of  the  thyroid  cartilage,  gives  off  no  cervical  branches,  but  ascends  to  the 
base  of  the  skull  along  the  lateral  wall  of  the  pharynx.  It  is  separated  from  the  external  carotid 
artery  by  the  styloglossus  and  stylopharyngeus  muscles.  It  pursues  a  curved  course  through 
the  carotid  canal  of  the  petrous  portion  of  the  temporal  bone  (see  Fig.  23),  the  concavity  of  the 
curve  being  directed  anteriorly.  This  leads  us  to  remark  that  fatal  hemorrhage  has  been  ob- 
served from  the  internal  carotid  artery  in  cases  of  caries  of  the  petrous  portion  of  the  temporal 
bone.  After  leaving  the  carotid  canal  the  vessel  passes  across  the  middle  lacerated  foramen  in 
the  carotid  sulcus  at  the  side  of  the  body  of  the  sphenoid  bone  and  is  enclosed  in  the  cavernous 
sinus.  It  then  ascends  to  the  optic  foramen,  where  it  describes  a  short  curve,  convex  forwards, 
from  which  is  given  off  the  only  branch  not  supplying  the  brain,  the  ophthalmic  artery,  which, 
together  with  the  optic  nerve,  enters  the  orbital  cavity  through  the  optic  foramen.  After  pene- 
trating the  dura,  the  internal  carotid  artery  reaches  the  base  of  the  brain  at  the  angle  between  the 
optic  nerve  and  the  optic  tract,  where  it  divides  into  two  main  branches,  the  anterior  and 
middle  cerebral  arteries. 

The  chief  branches  of  the  vertebral  and  basilar  arteries  which  supply  the  brain  are : 

1.  The  posterior  inferior  cerebellar  artery,  from  the  vertebral  to  the  lower  surface  of  the 
cerebellum. 

2.  The  anterior  inferior  cerebellar  artery,  from  the  basilar  to  the  lower  surface  of  the  cere- 
bellum. 

3.  The  superior  cerebellar,  which  arises  from  the  basilar  at  the  anterior  margin  of  the  pons 
and  ramifies  upon  the  superior  surface  of  the  cerebellum. 

4.  The  posterior  cerebral  arteries,  the  two  terminal  branches  of  the  basilar.  .  This  vessel  is 
separated  from  the  superior  cerebellar  at  its  origin  by  the  oculomotor  nerve  and  supplies  the  occip- 
ital lobe  and  the  greater  portion  of  the  temporal  lobe.  It  is  connected  with  the  internal  carotid 
by  the  posterior  communicating  artery. 

5.  The  internal  auditory  artery,  which  reaches  the  internal  ear  through  the  internal  auditory 
meatus. 

The  vertebral  artery  also  gives  off  lateral  spinal  branches  in  the  neck  which  pass  into  the 


Fig.  10 


Oculomotor  nerve 
Trochlear  nerve 
Left  posterior  cerebral  artery 
Right  posterior  cerebral  artery 
Aqueduct  of  Sylvius 
Tentorium  cerebelli 
Straight  sinus  Crura  cerebri 


Posterior  communicating  artery 
Abducent  nerve 


Optic  nerve 

Internal  carotid  artery 

Ophthalmic  nerve 

Superior  maxillary  nerve 

Semilunar  ganglion 
/*'«",  (Gasserian) 

Inferior  maxillary  nerve 

Middle  meningeal  artery 
Sphenoid  bone 
Dura  mater 

Temporal  artery 


Fig.  ii. 


Lesser  wing  of  the  . 
sphenoid  bone 

Oculomotor  nerve- 
Trochlear  nerve  

Abducent  nerve  • 
Ophthalmic  nerve - 

Superior  maxillary  nerve  - 
Dura  mater  - 


Optic  nerve 

Internal  carotid  arterv 

Hypophysis  cerebri 
Cavernous  sinus 

Sphenoidal  sinus 


CRANIOCEREBRAL    TOPOGRAPHY.  35 

vertebral  canal  through  the  intervertebral  foramina,  meningeal  branches  to  the  dura  mater  in  the 
posterior  cerebral  fossa,  and  the  anterior  and  posterior  spinal  branches  to  the  spinal  cord  and  its 
membranes. 

The  internal  carotid  artery  supplies  the  brain  with: 

1 .  The  anterior  cerebral  artery.  It  passes  inward  over  the  dorsal  surface  of  the  corresponding 
optic  nerve  and  then  forward,  approaching  the  artery  of  the  opposite  side,  with  which  it  is  con- 
nected by  the  anterior  communicating  artery.  The  vessels  winding  around  the  genu  of  the  corpus 
callosum  pass  backward,  supplying  the  corpus  callosum,  and  ramify  upon  the  median  surface 
of  the  cerebral  hemispheres. 

2.  The  middle  cerebral  artery,  which  runs  in  the  fissure  of  Sylvius,  supplying  the  frontal, 
parietal,  and  temporal  lobes  as  well  as  the  island  of  Reil. 

3.  The  anterior  choroid  artery,  passing  posteriorly  along  the  optic  tract  to  the  descending 
horn  of  the  lateral  ventricle  to  enter  the  choroid  plexus. 

4.  The  posterior  communicating  artery,  which  has  been  previously  mentioned. 

CRANIOCEREBRAL  TOPOGRAPHY. 

The  tentorium  cerebelli  (see  Figs.  2,  9,  17,  and  Plate  4)  divides  the  cranial  cavity  into  two 
closed  spaces  which  communicate  with  each  other  through  the  incisura  tentorii.  The  larger 
anterior  space  includes  the  anterior  and  middle  cranial  fossas  and  lodges  the  cerebrum;  the 
small  posterior  space — the  posterior  cranial  fossa — contains  the  cerebellum,  the  pons,  and  the 
medulla.  A  frontal  section  through  the  back  part  of  the  head,  posterior  to  the  incisura  tentorii 
(see  Fig.  12),  reveals  four  separate  compartments  having  apparently  no  connection  with  each 
other,  since  the  falx  cerebri,  the  falx  cerebelli,  and  the  tentorium  form  a  cross-like  partition 
which  separates  the  hemispheres  of  the  cerebrum  and  cerebellum.  The  plane  of  such  a  cross- 
section  will  be  better  understood  after  a  study  of  other  illustrations  (Fig.  9,  Plate  4).  The 
following  relations  will  be  made  more  clear  to  the  mind  of  the  reader  by  looking  at  the  base  of 
a  skull  (see  Fig.  9  and  Plate  1). 

The  anterior  cranial  fossa  lodges  the  frontal  lobes  of  the  cerebrum ;  the  marked  develop- 
ment of  the  juga  (ridges)  cerebralia  and  of  the  impressiones  digitatae  on  the  thin  orbital  plate  of 
the  frontal  bone  are  due  to  the  orbital  sulci  and  gyri  respectively.  In  the  median  line  the 
olfactory  bulb  rests  upon  the  cribriform  plate  of  the  ethmoid  and  gives  off  the  olfactory  filaments 
to  the  nasal  cavity. 

The  middle  cranial  fossa  contains  the  temporal  lobes.  Its  posterior  and  lateral  portion  bears 
an  important  relation  to  the  roof  of  the  middle  ear  (tegmen  tympani).  This  is  the  situation  at 
which  abscesses  develop  in  the  temporal  lobes  as  the  result  of  suppurations  in  the  middle  ear. 
Another  important  situation  in  the  middle  cranial  fossa  is  located  anteriorly  near  the  median  line, 
where  the  large  semilunar  ganglion  is  found  with  its  three  main  divisions  (see  page  32).  The  pos- 
terior border  of  the  lesser  wing  of  the  sphenoid  corresponds  to  the  deep  fissure  of  Sylvius  situated 
between  the  frontal  and  temporal  lobes.  The  optic  chiasm,  giving  off  the  optic  nerves,  is  situated 
anteriorly  in  the  narrow  median  portion  of  the  middle  cranial  fossa.  Further  posteriorly,  the 
hypophysis  cerebri  is  imbedded  in  the  sella  turcica. 


36 


TOPOGRAPHIC    AND   APPLIED    ANATOMY. 


PLATE  3. 

The  base  of  the  brain  with  the  twelve  cranial  nerves  and  the  cerebral  arteries. 

The  incisura  tentorii  transmits  the  so-called  isthmus  cerebri,  which  is  formed  ventrally  by 
the  crura  and  dorsally  by  the  corpora  quadrigemina.  The  occipital  lobes  of  the  cerebrum  rest 
upon  the  tentorium;  the  lower  surface  of  the  tentorium  covers  the  upper  surface  of  the  cere- 
bellum, the  hemispheres  of  which  fill  the  deepest  portions  of  the  posterior  cranial  fossa  (fossae 
occipitales).     The  pons  lies  upon  the  upper  two-thirds  of  the  clivus,  its  anterior  border  almost 


Sagittal  suture- 
Cerebral  veins--- 


Occipital  lobe 


Straight  sinus 


Lambdoidal  suture 
Transverse  sinus 


Fig.  12. — A  frontal  section  through  the  posterior  portion  of  the  head  (frozen  section).  Anterior  view.  The 
section  strikes  the  falx  cerebri,  the  falx  cerebelli,  and  the  tentorium  cerebelli  in  such  a  way  that  the  cranial  cavity  seems 
to  contain  four  apparently  separate  compartments,  in  which  may  be  seen  the  two  cerebral  and  the  two  cerebellar 
hemispheres. 

reaching  to  the  dorsum  of  the  sella  turcica.  The  lower  third  of  the  clivus,  as  far  down  as  the 
foramen  magnum,  lodges  the  anterior  portion  of  the  medulla  oblongata  which  extends  to  the 
upper  margin  of  the  posterior  arch  of  the  atlas.  A  median  sagittal  section  (see  Plate  4)  shows 
that  the  pons  and  medulla  assume  an  almost  vertical  position.  It  should  also  be  observed  that  the 
cerebrum  is  much  more  exposed  to  external  injuries  than  is  the  better  protected  cerebellum. 

As  it  is  occasionally  necessary  to  open  the  cranial  cavity  and  expose  definite  regions  of  the 


Superior  longitudinal  sinus 


Lobs.   Frontal  lobe 


Optic  n 
Hypophysis 
Temporal  lobe 

Oculomotor  nerve 
Trochlear  nerve 

Trifacial  nerve 
Alxlurcnt  nerve 


Auditory  nerve 
Facial  nerve 
ti!<*.sopharynj»eal  n 
Pneiunogastric  n 

Sjiinal  accessory  n 


Medulla  oblongata 


Cerebellum 


SinuSinus  occipitalis 


Frontalis  m. 
Frontal  bougie 

Dura  mataatci 

Olfactory  bulb 


Temporalis  m. 

Olfactory  traefectoriu8 

Anterior  commu- 
nicating artery 
Ant.  cerebral  a. 

Middle  cerebrala. 
Intern,  carotid  a. 


Posterior  commu- 
nicating artery 


Post,  cerebral  a. 
Sup.  cerebellar  a. 
Parietal  bone 
Pons  DM 

Ant.    inf.    cere- 
bellar artery  ' 
Basilar  artery 

Vertebral  artery 

Post.  inf.  cere- 
bellar artery 

Anterior  spinal 
artery 


Occipital  bone 


Occipitalis  muscle 


3<> 


•   PI 


The 

... 

upon  the  t« 


it  rally  by 
he  cerebrum 
N^  e  of  the 

I >■  ■  *iialiBfcirtii8>»4v 

/  the  cli-  \       jorder  a! 

T3)£m  rmQ- 


dlud  yioJmUO 


Sagittal  Htm 
.m  ziLnoqawT 


-utamot  lonoinA 
^TitTB  xniiBjin 

.£  bncfoiaj  .la A 

.Bljndnw^lhbiM 

.«  bilouo  (itiimI 

-oinmooioh'ii^i 
\(t»1-lb  an''"'" 

.£  UiWstsd  .tool 


l  fi(Iui»ll 


mulMiio') 


slv.um  eilsliqbsO 
UPP 


^^^~*^  i  as  the 

1]  ads  to  the 

hows 
■   ed  that  the 
x'llum. 


7ab.i- 


Sinus  sagittalis  sup 


Lobus  frontalis 


N.  opticus 
Hypophysis 
Lobus  temporalis   _/ 

N.  oculomotorius  / 

N.  trochlearis    J 

N.  trigeminus 
N.  abducens 

N.  acusticus 

N.  facialis 

N.  glossopharyngeus 

N.  vagus 
N.  accessorius 


Medulla  oblongata 


Cerebellum 


Sinus  occipitalis 


M.  frontalis 
Os  frontale 

Dura  mater 


Bulbus  olfactorius 

M.  temporalis 
m  A  Tractus  olfactorius 

^_  A.communicans  ant 
A.  cerebri  anterior 

A.  cerebri  media 
A.carotis  interna 
A.communicans  poj 

A.  cerebri  post. 
A.  cerebelli  sup. 
Os  parietale 
-  - Pons 


A.  cerebelli  inf.  ant 
--  A.  basilaris 
A.  vertebralis 

A.  cerebelli  inf.  post 
-A.  spinalis  ant. 


Os  occipitale 


M.  occipitalis 


CRANIOCEREBRAL    TOPOGRAPHY. 


37 


cerebral  surface  (in  cases  of  cerebral  abscess,  tumors,  and  operations  upon  the  cortex),  the  surgeon 
needs  certain  lines  as  aids  in  the  localization.  In  consequence  of  the  manifold  variations  in  the 
shape  of  the  skull,  these  lines  are  not  absolutely  accurate  in  all  cases,  but  they  nevertheless  furnish 
indispensable  guides.  An  exact  topographic  localization  is  never  possible  until  the  surgeon  has 
made  an  extensive  opening  in  the  skull  and  exposed  the  cerebral  surface.  Kronlein  recommends 
the  following  lines  (see  Fig.  13): 


FlG.  13. — Craniocerebral  topography  (after  Kronlein  and  Froriep).     Explanation  in  the  text. 


i.  The  base-line  (horizontal  line,  ear-orbit  line)  through  the  infraorbital  margin  and  the 
upper  border  of  the  external  auditory  meatus  (Re id's  base-line). 

2.  The  superior  horizontal  line  through  the  supraorbital  margin,  parallel  to  the  base-line 
(line  of  Kronlein). 

3.  The  anterior  vertical  line,  at  right  angles  to  the  base-line  at  the  middle  of  the  zygoma. 


38  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

4.  The  middle  vertical  line,  at  right  angles  to  the  base-line  from  the  condyloid  process  of  the 
mandible. 

5.  The  posterior  vertical  line  at  right  angles  to  the  base-line  from  the  most  posterior  portion 
of  the  base  of  the  mastoid  process. 

If  the  point  of  intersection  of  the  anterior  vertical  with  the  superior  horizontal  line  is  connected 
with  the  point  where  the  posterior  vertical  line  strikes  the  vertex  [that  is,  the  antero-posterior 
median  line  of  the  vertex. — Ed.],  we  have: 

6.  The  linea  Rolandi,  corresponding  to  the  fissure  of  Rolando. 

If  the  angle  formed  by  the  superior  horizontal  line  with  the  line  of  Rolando  is  bisected  and 
the  bisecting  line  is  extended  to  the  posterior  vertical  line,  we  have : 

7.  The  linea  Sylvii,  corresponding  to  the  fissure  of  Sylvius. 
The  following  is  an  explanation  of  the  letters  in  Fig.  13: 

K,  Junction  of  the  horizontal  with  the  vertical  limb  of  the  fissure  of  Sylvius. 

S,  Upper  end  of  the  fissure  of  Sylvius. 

R,  Lower  end  of  the  fissure  of  Rolando. 

K  and  K',  indicate  the  two  trephine  openings  of  Kronlein  for  the  anterior  and  the  posterior 
branches  respectively  of  the  middle  meningeal  artery  (see  page  29).  The  rectangle  ABK'M 
corresponds  to  the  area  resected  by  v.  Bergmann  as  a  preliminary  step  to  operative  measures 
in  the  middle  cerebral  fossa. 

QUESTIONS. 

How  should  the  frontal  sinus  be  opened  in  order  to  reach  its  communication  with  the  nasal  cavity  ? 

What  fontanelles  are  felt  in  the  head  of  the  new-born? 

How  may  subcutaneous  emphysema  be  produced  after  the  frontal  sinuses  have  been  opened? 
.   To  what  extent  may  the  withdrawal  of  blood  from  the  scalp — from  behind  the  ear,  for  example 
— aid  in  diminishing  increased  intracranial  blood-pressure  ? 

Which  cranial  nerves  are,  as  a  result  of  their  course,  particularly  apt  to  be  affected  in  basal  frac- 
tures and  compressed  against  the  base  by  tumors  ?     What  is  characteristic  of  this  course  ? 

From  what  situation  in  the  face  is  it  possible  to  wound  the  brain  without  a  concomitant  injury  of 
the  cranial  bones? 

Is  the  escape  of  blood  or  cerebrospinal  fluid  from  the  nose,  in  cases  of  basal  fractures,  of  any  value 
in  localizing  the  seat  of  the  fracture  ?     If  not,  why  ?     What  vessels  may  be  involved  ? 

Where  are  the  places  at  the  base  of  the  skull  which  are  pushed  against  the  brain  by  tumors  growing 
from  the  sphenoidal  sinus  or  from  the  ethmoidal  cells  ?    Find  these  places  in  the  illustrations. 

What  difference  exists  between  the  skin  of  the  scalp  and  the  scalp  proper,  and  how  is  the  mova- 
bility  of  both  affected  by  their  anatomic  structure  ? 

Why  is  it  that  cutaneous  wounds  of  the  scalp  do  not  gape  while  wounds  involving  the  entire 
scalp  do? 

Why  is  it  impossible  to  close  large  cutaneous  defects  in  the  scalp  by  uniting  the  edges  of  the  wound  ? 

What  are  the  characteristics,  dependent  upon  anatomic  structure,  of  an  effusion  of  blood  or  of  a 
suppuration  in  the  scalp  ?     Beneath  the  scalp  ? 

Why  does  the  skin  of  the  scalp  bleed  more  profusely  after  injur)-  than  that  of  any  other  cutaneous 
area  ?    Why  do  large  flaps  in  this  situation  adhere  more  readily  than  elsewhere  ? 


THE    FACE.  39 

Where  may  the  pulsations  of  the  temporal  artery  be  felt ? 

In  what  situations  may  neurectomy  of  the  supraorbital  and  of  the  occipitalis  major  nerves  be  per- 
formed ? 

Into  what  cleft-like  spaces  may  the  blood  be  poured  from  a  wound  of  the  middle  meningeal  artery? 

What  are  the  locations  of  the  trephine  openings  for  both  branches  of  the  middle  meningeal  artery? 

How  is  access  to  the  lateral  sinus  best  gained  from  the  exterior  ?  What  is  the  relation  of  the 
lateral  sinus  to  the  mastoid  cells  ? 

What  is  the  explanation  of  the  symptom  of  pulsating  exophthalmos  ? 

How  is  the  semilunar  ganglion  best  exposed  from  the  outside  of  the  skull,  and  what  neighboring 
structures  are  thereby  endangered  ? 

Which  cranial  nerves  and  which  large  arteries  are  endangered  in  fractures  of  caries  of  the  petrous 
portion  of  the  temporal  bone  ? 

Which  lobe  of  the  brain  lies  upon  the  tegmen  tympani?     Why  is  it  important  to  know  this? 

THE  FACIAL  REGION. 
THE  FACE. 

The  skin  of  the  face,  on  account  of  its  thinness  and  vascularity,  furnishes  the  physician  with 
an  important  diagnostic  aid  in  forming  a  conclusion  as  to  the  general  condition  of  his  patient 
(redness,  paleness, cyanosis).  In  contrast  to  the  skin  of  the  scalp  (see  page  24),  it  possesses  great 
movability,  which,  together  with  its  vascularity,  markedly  favors  the  performance  of  plastic 
operations.  The  connection  of  the  skin  with  the  muscles  of  expression  is  a  further  character- 
istic demanding  attention.  Effusions  of  blood  into  the  loose  subcutaneous  tissue  spread  dif- 
fusely, so  that  sharply  circumscribed  swellings  are  not  observed  after  contusions;  in  dropsy  the 
entire  face  may  be  swollen.  [Because  of  its  vascularity  facial  wounds,  even  when  much  lacerated 
and  contused,  heal  rapidly. — Ed.] 

The  bony  framework  of  the  face,  the  facial  skeleton,  is  composed  of  the  fourteen  facial  bones. 
Six  of  these  are  paired:  the  superior  maxilla,  the  palatine,  the  malar,  the  nasal,  the  lachrymal, 
and  the  inferior  turbinated  bones.  The  remaining  two  are  single  bones,  the  inferior  maxilla 
and  the  vomer.  The  bones  as  well  as  the  large  portion  of  the  ethmoid  entering  into  the  facial 
skeleton  should  be  reviewed  in  a  systematic  text-book  and  with  specimens ;  the  same  is  true  of  the 
muscles  of  expression  and  of  mastication. 

Arteries. — Disregarding  the  branches  which  extend  into  the  face  from  the  vessels  of  the 
cranial  region,  the  four  main  trunks  particularly  supplying  the  face  are: 

1.  The  facial  artery,  from  the  external  carotid  (see  Plate  2). 

2.  The  internal  maxillary  artery,  one  of  the  terminal  branches  of  the  external  carotid. 

3.  The  ophthalmic  artery,  from  the  internal  carotid  (see  Plate  18). 

4.  The  lingual  artery,  from  the  external  carotid  (see  page  64). 

In  addition  to  these  vessels,  there  are  some  small  branches  of  the  temporal  artery,  such  as 
those  passing  to  the  parotid  gland  and  to  the  auricle,  as  well  as  the  transverse  facial  artery  below, 
and  the  orbital  artery  above,  the  zygoma  (Plate  2). 

The  facial  artery  in  the  neck  runs  in  the  submaxillary  triangle,  imbedded  in  the  substance  of 
the  submaxillar}-  gland  [imbedded  in  a  groove  on  the  posterior  end  of  the  submaxillar}- gland,  which 


40  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

Fig.  14. — The  relations  of  the  vessels  and  of  the  facial  nerve  within  and  beneath  the  parotid  gland.     The  gland  has 

been  divided  by  a  vertical  incision. 

separates  it  from  the  more  superficial  facial  vein  (Cunningham). — Ed.],  and  crosses  the  border  of 
the  jaw  at  the  anterior  margin  of  the  masseter  muscle.  At  this  point  the  pulsations  of  the  vessel 
may  be  felt  and,  in  a  given  case,  hemorrhage  may  be  temporarily  arrested  by  pressure  against  the 
jaw-bone.  The  artery  then  pursues  a  more  or  less  sinuous  course  upon  the  buccinator  and 
levator  anguli  oris  muscles  and  reaches  the  side  of  the  nose,  where  it  anastomoses,  as  the  angular 
artery,  with  the  dorsalis  nasi  artery  coming  out  of  the  orbit  from  the  ophthalmic.  It  also  forms 
variable  anastomoses  with  the  buccal  and  infraorbital  branches  of  the  internal  maxillary.  In 
the  neck  the  vessel  gives  off  the  ascending  palatine  artery,  frequently  an  independent  branch 
of  the  external  carotid,  which  ascends  between  the  styloglossus  and  stylopharyngeus  muscles  to 
the  muscles  of  the  palate  and  pharynx,  giving  off  a  tonsillar  branch  (see  page  57);  the  submental 
is  another  cervical  branch  which  passes  forward  below  (i.  e.,  on  the  outer  surface  of)  the  mylo- 
hyoid muscle  and  is  covered  by  the  submaxillary  gland.  In  the  face  the  artery  gives  off  the 
superior  and  inferior  coronary  arteries  which  supply  the  mucous  membrane  of  upper  and  lower 
lips  and  anastomose  in  the  median  line  with  their  fellows  of  the  opposite  side. 

The  internal  maxillary  artery,  one  of  the  terminal  branches  of  the  external  carotid,  arises 
in  the  substance  of  the  parotid  gland  behind  the  neck  of  the  condyle  of  the  lower  jaw  and 
passes  to  the  spheno-maxillary  fossa.  The  branches  worthy  of  mention,  in  addition  to  those 
supplying  the  muscles  of  mastication,  are  the  inferior  dental  (passing  though  the  inferior  dental 
canal  in  company  with  the  nerve  of  the  same  name  and  escaping  from  the  mental  foramen),  the 
middle  meningeal  (see  page  29),  the  infraorbital  (passing  through  the  infraorbital  canal  with  the 
nerve  of  the  same  name  to  make  its  exit  at  the  infraorbital  foramen),  the  superior  alveolar  to  the 
teeth  of  the  upper  jaw,  the  posterior  palatine  and  the  pterygopalatine  to  the  palate  (naso-pharynx) 
(through  the  foramina  of  the  same  name),  and  the  sphenopalatine,  which  passes  through  the 
sphenopalatine  foramen  to  the  nasal  cavity. 

The  chief  vein  of  the  face  is  the  facial,  which  commences  as  the  angular  vein,  formed  by  the 
union  of  frontal  and  supraorbital  veins  (see  Plate  2).  It  is  situated  behind  the  facial  artery  and, 
though  superficial  to  this  vessel,  passes  beneath  the  zygomaticus  major  muscle  to  the  angle  of  the 
jaw,  where  it  unites  with  the  anterior  division  of  the  temporo-maxillary  vein  to  form  a  trunk  which 
empties  into  the  internal  jugular.  The  temporo-maxillary  vein  is  formed  in  the  substance  of  the 
parotid  gland  by  the  union  of  the  temporal  with  the  internal  maxillary,  the  latter  vessel  receiving 
blood  from  the  pterygoid  plexus  in  the  spheno-maxillary  fossa.  [It  divides  at  the  lower  part  of 
the  parotid  gland  into  an  anterior  division,  joined  by  the  facial,  and  a  posterior,  which  with  pos- 
terior auricular  makes  up  the  external  jugular  vein. — Ed.]  The  ophthalmic  veins  are  described 
upon  page  46. 

The  nerves  of  the  face,  in  addition  to  those  supplying  the  posterior  portion  of  the  cranial 
region  (see  page  27),  are: 

Sensory' :  1.  The  infraorbital  nerve,  the  termination  of  the  superior  maxillary  (second  divi- 
sion of  the  fifth),  making  its  exit  from  the  infraorbital  foramen.  The  superior  maxillary  nerve 
reaches  the  orbit  through  the  spheno-maxillary  fissure  and  runs  forward  as  the  infraorbital  nerve 


Fig.  ,4. 


Parietal   branch    of 
temporal  artery 


Cut  surface   of  the 
parotid  gland 
Branch  of  facial  nerve 

Temporo-maxillary  vein 
External  carotid  artery 
Branch  of  facial  nerve 


Frontal  branch  of 
temporal  artery 


Transverse   facial 

artery 
Cut  surface  of  the 

parotid  gland 
Parotid  duct 
M.  masseter 
Buccal  branches  of 
facial  nerve 


M.  platysma 

myoides 
Facial  artery 


THE    FACE.  41 

in  the  sulcus  and  canal  of  the  same  name  in  the  roof  of  the  maxillary  sinus  (see  Figs.  11  and  16). 
Neurectomy  is  sometimes  demanded  for  the  relief  of  severe  neuralgia  in  this  region.  The  nerve 
may  be  resected  above  the  second  biscuspid  tooth  at  the  infraorbital  foramen,  but  it  is  better  to 
make  an  incision  down  to  the  bone  parallel  to  and  below  the  infraorbital  margin,  elevating  the 
orbital  contents  with  a  spatula,  and  resecting  the  nerve  as  far  back  as  possible  in  the  infraorbital 
fissure,  after  which  the  peripheral  portion  may  be  torn  out  through  the  infraorbital  foramen. 
[The  infraorbital  foramen  is  about  one-third  of  an  inch  below  the  lower  margin  of  the  orbit, 
opposite  the  junction  of  inner  and  middle  thirds  of  this  margin,  and  can  usually  be  easily  located 
with  the  finger. — Ed.]  In  this  operation  the  alveolar  branches  to  the  teeth  of  the  upper  jaw  are, 
of  course,  torn  away  from  the  excised  portion  of  the  nerve.  The  nerve  may  also  be  exposed  at 
the  infraorbital  foramen  from  the  vestibulum  oris.  Since  the  infraorbital  nerve  runs  in  the 
relatively  thin  roof  of  the  maxillary  sinus  (see  Figs.  15  and  16)  care  must  be  taken  to  avoid  injury 
to  the  sinus,  which  may  lead  to  subcutaneous  emphysema  of  the  orbit.  Air  entering  the  orbit  in 
this  manner  may  cause  exophthalmos.  [When  it  is  deemed  necessary  to  expose  and  resect 
Meckel's  ganglion  as  well  as  the  infraorbital  nerve,  this  is  best  accomplished  by  trephining  the 
anterior  wall  of  the  maxillary  sinus,  opening  the  bony  canal  of  the  infraorbital  from  beneath, 
and  trephining  the  posterior  wall  of  the  sinus,  thus  opening  the  spheno-maxillary  fossa.  The 
ganglion  is  slightly  below  the  main  trunk  of  the  nerve  and  in  intimate  relation  with  the  terminal 
branches  of  the  internal  maxillary  artery.  By  this  route  the  superior  maxillary  division  of  the 
fifth  nerve  may  be  easily  followed  to  its  exit  from  the  foramen  rotundum. — Ed.] 

The  inferior  dental  nerve,  a  branch  of  the  inferior  maxillary  division  of  the  fifth,  passes 
through  the  inferior  dental  canal,  supplies  the  teeth  of  the  lower  jaw,  and  makes  its  exit  at  the 
mental  foramen  below  the  second  biscuspid  tooth  to  be  distributed  to  the  skin  of  the  chin 
(see  Fig.  1).  This  nerve  is  also  occasionally  resected,  the  mental  foramen  being  exposed  from 
the  vestibulum  oris  or  by  direct  incision  of  the  overlying  structures.  In  addition  to  this,  the 
nerve  may  be  exposed  by  chiseling  open  or  by  trephining  the  infraorbital  canal  between  the 
angle  of  the  jaw  and  the  coronoid  process. 

The  important  motor  nerve  of  the  face  is  the  seventh  cranial  nerve,  the  facial  nerve.  Its 
course  in  the  petrous  portion  of  the  temporal  bone  (entrance  at  the  internal  auditory  meatus, 
exit  at  the  stylomastoid  foramen)  and  its  not  infrequent  involvement  in  caries  or  fracture  in  this 
situation  have  been  previously  mentioned  (see  page  32).  After  its  exit  from  the  bone,  the  nerve 
soon  imbeds  itself  in  the  parotid  gland,  from  the  anterior  border  of  which  its  numerous  branches 
pass  to  the  facial  muscles  (see  Fig.  14).  The  nerve  may  be  exposed  at  its  exit  from  the  stylomas- 
toid foramen  by  entering  behind  the  styloid  process  to  the  inner  side  of  the  mastoid  process. 

The  parotid  gland  covers  the  posterior  part  of  the  masseter  muscle  as  well  as  the  temporo- 
maxillary  articulation  and  a  considerable  portion  of  its  substance  extends  deeply  into  the  retro- 
mandibular fossa,  bounded  in  front  by  the  ramus  of  the  jaw  and  behind  by  the  external  auditory 
meatus  and  the  mastoid  process.  The  parotid  duct,  frequently  in  relation  with  a  socia  parotidis, 
passes  anteriorly  across  the  masseter  and  perforates  the  buccinator  muscle  to  open  into  the 
mouth  opposite  the  second  upper  bicuspid  tooth.  The  orifice  of  the  duct  may  be  made  accessible 
for  probing  by  introducing  the  finger  into  the  angle  of  the  mouth  and  drawing  the  cheek  away 
from  the  teeth. 


42  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

The  relation  of  the  parotid  gland  to  the  retromandibular  fossa  furnishes  sufficient  explanation 
for  the  pain  produced  by  mastication  when  the  gland  is  inflamed  and  swollen.  Since  the  parotid 
extends  inward  toward  the  pharynx  it  will  be  readily  understood  that  large  tumors  proceeding 
from  the  parotid  gland  cause  dysphagia  from  compression  of  the  pharynx.  The  proximity  of  the 
external  auditory  meatus  explains  the  occasional  perforation  of  parotid  abscesses  into  this  canal. 

In  operative  procedures  upon  the  parotid  gland  it  is  rather  difficult  to  avoid  dividing  branches 
of  the  facial  nerve,  the  resulting  paralysis  usually  being  of  a  temporary  character.  It  should  be 
remembered  that  the  trunk  of  the  facial  nerve  enters  the  parotid  gland  from  above  and  behind, 
at  a  point  on  a  level  with  the  base  of  the  lobule  of  the  ear.  In  total  extirpation  of  the  gland 
it  is  scarcely  possible  to  avoid  injuring  the  trunk.  In  operations  penetrating  deeply  into  the 
retro-mandibular  fossa,  it  is  important  to  remember  that  the  external  carotid  artery,  as  well  as 
numerous  veins  (particularly  the  temporo-maxillary),  are  in  close  relation  with,  or  imbedded  in, 
the  median  surface  of  the  gland.  [The  temporo-maxillary  vein  and  the  external  carotid  artery 
usually  traverse  the  substance  of  the  gland,  the  vein  being  superficial  to  the  artery  and  deeper 
than  the  facial  nerve. — Ed.]  Still  more  deeply  are  found  the  internal  carotid  artery  and  the 
internal  jugular  vein. 

THE  ORBITAL  CAVITY. 

The  shape  of  the  bony  orbit  may  be  compared  to  that  of  a  four-sided  hollow  pyramid,  the 
base  being  situated  at  the  margin  of  the  orbit  and  the  apex  at  the  optic  foramen.  [The  inner 
walls  are  almost  parallel;  the  outer  walls  if  prolonged  backward  would  meet  in  almost  a  right 
angle.  The  depth  of  the  orbit  is  from  i  f  to  2  inches. — Ed.]  It  should  be  carefully  studied  from 
a  skull. 

The  upper  wall  is  formed  by  the  very  thin  orbital  plate  of  the  frontal  bone  (see  Figs.  1  and  16) 
and  a  small  posterior  portion  by  the  lesser  wing  of  the  sphenoid.  Externally  beneath  the  zygo- 
matic (external  angular)  process  is  the  lachrymal  fossa,  which  lodges  the  lachrymal  gland; 
internally  is  a  small  depression,  the  fovea  trochlearis  (occasionally  also  a  spina  trochlearis), 
for  the  attachment  of  the  pulley  of  the  superior  oblique  muscle.  In  the  supraorbital  margin 
toward  the  inner  side  [near  the  junction  of  the  inner  and  middle  thirds. — Ed.]  is  the  supra- 
orbital notch  or  foramen  for  the  passage  of  the  nerve  and  artery  of  the  same  name. 

The  inner  wall  is  formed  by  the  lachrymal  bone,  the  os  planum  of  the  ethmoid,  and  poste- 
riorly by  a  portion  of  the  lateral  surface  of  the  body  of  the  sphenoid.  Anteriorly  is  a  depression 
for  the  lachrymal  sac  (and  duct)  (fossa  saccilachrymalis),  bounded  by  the  inner  extremity  of  the 
supraorbital  margin  (crista  lachrymalis  anterior  of  the  superior  maxilla)  and  by  the  lachrymal 
crest  of  the  lachrymal  bone  (crista  lachrymalis  posterior) ;  from  this  point  a  sound  may  easily  be 
passed  downward  into  the  nasal  duct  which  opens  into  the  inferior  meatus  of  the  nose.  Further 
posterior  on  the  inner  wall  [between  the  os  planum  of  the  ethmoid  and  the  orbital  plate  of  the 
frontal. — Ed.]  are  situated  the  anterior  ethmoidal  foramen,  communicating  with  the  cranial 
cavity,  and  the  posterior  ethmoidal  foramen,  leading  to  the  posterior  ethmoidal  cells. 

The  lower  wall  is  formed  by  the  orbital  surface  of  the  superior  maxilla  containing  the  in- 
fraorbital groove  and  canal,  which  terminates  anteriorly  beneath  the  lower  margin  of  the  orbit  at 
the  infraorbital  foramen  and  transmits  the  artery  and  nerve  of  the  same  name  (see  Figs.  1  and  16). 


THE    ORBITAL    CAVITY. 


43 


[The  bony  roof  of  this  canal  is  usually  deficient  behind. — Ed.]  The  external  portion  of  the  lower 
wall  is  formed  anteriorly  by  the  orbital  process  of  the  malar  bone ;  the  orbital  process  of  the 
palate  bone  also  aids  in  forming  the  most  posterior  portion  of  the  floor. 

The  outer  wall  consists  anteriorly  of  the  orbital  process  of  the  malar  bone,  posteriorly  of  the 
orbital  surface  of  the  great  wing  of  the  sphenoid,  and  above  and  anteriorly  of  the  zygomatic 
(external  angular)  process  of  the  frontal  bone.  This  surface  presents  the  small  temporomalar 
canals  for  the  temporal  and  malar  branches  of  the  orbital  nerve. 

In  addition  to  the  optic  foramen,  which  transmits  the  optic  nerve  and  the  ophthalmic  artery, 
another  communication  between  the  bony  orbit  and  the  cranial  cavity  is  furnished  by  the 
sphenoidal  fissure  (transmitting  the  oculomotor,  the  trochlear,  the  ophthalmic,  and  the 
abducent  nerves  and  the  ophthalmic  vein).     The  spheno-maxillary  fissure  (for  the  infraorbital 


Orbital  plate  of 
frontal  bone 

Crista  galli 

Sphenoidal 

fissure 

Great  wing  of 
sphenoid  bone 
Zygomatic  pro- 
cess of  frontal 
Optic  foramen 

Sphenomaxillary 

fissure 
"  Infraorbital  canal 

Maxillary  sinus 


Ethmoidal  cells_.___ 


Perpendicular 

plate  of  ethmoid 

bone 


Inferior 
turbinated  bone 


—  Alveolar  process 


Fig.  15. — A  frontal  section  of  the  bony  orbits  of  the  nasal  cavities  and  of  the  maxillary  sinuses. 


vein)  communicates  in  its  anterior  portion  with  the  temporal  fossa;  the  posterior  portion  is  in 
connection  with  the  spheno-maxillary  fossa.  [In  this  fissure  are  found  the  infraorbital  artery 
as  well  as  the  vein,  the  superior  maxillary  division  of  the  fifth  nerve,  the  orbital  branches  of  the 
same  nerve,  and  twigs  from  Meckel's  ganglion. — Ed.] 

The  external  wall  of  the  orbit  is  the  strongest.  The  other  walls  are  weaker  and  are  conse- 
quently thereby  predisposed  to  perforation. 

Since  the  floor  of  the  orbit  is  the  roof  of  the  maxillary  sinus  and  the  os  planum  in  the  inner 
wall  covers  in  the  ethmoidal  cells,  it  will  be  understood  that  when  these  walls  are  perforated, 
the  air  from  these  accessory  cavities  may  enter  the  orbit  and  cause  emphysema  and  exophthalmos. 
This  may  also  be  occasionally  observed  after  perforation  of  the  orbital  roof,  since  the  frontal 
sinus  frequently  extends  into  the  upper  wall  of  the  orbit,  in  rare  cases  as  far  as  the  optic  foramen 
(see  Fig.    15).     The    relatively   thin   bony   laminae   separating  the   orbital   cavities  from  the 


44  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

Fig.  i 6. — A  frontal  section  of  the  head  through  the  orbital  cavities  and  the  maxillary  sinuses  (frozen  section). 

anterior  cranial  fossa,  the  ethmoidal  cells,  the  maxillary  sinus,  and  the  frontal  sinus,  furnish  an 
explanation  for  the  fact  that  tumors  growing  from  these  adjoining  regions  may  invade  the  orbit, 
displace  the  eyeball,  and  endanger  the  orbital  contents. 

The  periosteum  lining  the  orbit  is  known  as  the  periorbita. 

The  eyelids  are  formed  from  cutaneous  folds  which  grow  over  the  protruding  eyeball  during 
fetal  life  and  become  temporarily  adherent  along  the  line  of  the  palpebral  fissure.  At  this  fissure 
the  skin  is  continuous  with  the  mucous  membrane  lining  the  inner  surface  of  the  lid  (palpebral 
conjunctiva)  which  is  reflected  to  the  eyeball  at  the  fornix  to  pass  anteriorly  to  the  corneal  margin  as 
the  ocular  conjunctiva.  Foreign  bodies  gaining  access  to  the  conjunctival  sac  occasionally  become 
firmly  lodged  in  the  conjunctival  fornix.  The  orbicularis  palpebrarum  muscle  lies  immediately 
beneath  the  skin,  which  possesses  no  subcutaneous  fat.  This  muscle  extends  over  the  orbital 
margin  and  consists  of  an  orbicular  portion,  of  a  palpebral  portion,  and  of  a  lachrymal  portion 
[the  tensor  tarsi — Horner's  muscle. — Ed.],  the  latter  being  a  small  bundle  of  fibers  passing  behind 
the  lachrymal  sac.  The  eyelids  receive  a  certain  degree  of  solidity  from  the  plates  of  connective 
tissue  of  the  so-called  tarsal  cartilages,  which  are  better  developed  in  the  upper  than  in  the  lower 
lids.  In  the  upper  lid  this  cartilage  contains  thirty  to  forty,  in  the  lower  lid,  twenty  to  thirty 
Meibomian  glands,  alveolar  structures  closely  related  to  the  sebaceous  glands,  which  open  at  the 
anterior  margin  of  the  lid  and  consequently  upon  the  external  cutaneous  surface.  They  oc- 
casionally lead  to  the  formation  of  retention  cysts  and  abscesses  (stye,  hordeolum).  In  front  of 
the  orifices  of  these  glands,  at  the  margin  of  the  lids,  the  cilia  are  arranged  in  two  or  three  rows. 
Their  abnormal  growth  toward  the  eyeball  leads  to  the  disturbances  of  trichiasis  and  distichiasis. 
The  tarsal  ligament  or  orbital  septum  [palpebral  ligaments  of  English  authors,  who  apply  the 
term  "  tarsal  ligaments "  to  the  bands  which  attach  the  inner  and  outer  extremities  of  the 
tarsal  cartilage  to  the  superior  maxilla  and  malar  bone  respectively. — Ed.]  is  a  dense  lamina 
of  connective  tissue  extending  in  a  frontal  plane  from  the  periosteum  of  the  edge  of  the 
orbit  to  the  ciliary  margin  of  the  tarsal  cartilage.  It  serves  to  close  off  the  orbital  cavity 
from  the  eyelids  and  may  offer  a  certain  degree  of  resistance  to  the  extension  of  inflam- 
mations from  within  outward  or  in  the  opposite  direction.  This  orbital  septum  is  pierced 
by  the  vessels  and  nerves  passing  from  the  orbit  to  the  frontal  region. 

When  the  lids  are  closed,  the  conjunctival  sac  is  a  slit-like  space  bounded  by  the  palpebral 
conjunctiva,  the  orbital  conjunctiva,  and  the  anterior  surface  of  the  cornea.  It  is  deepest  at  the 
middle  of  the  eyelid,  so  that  if  the  line  of  the  fornix  were  projected  upon  the  eyelid  it  would  form 
a  circular  line  the  diameter  of  which  would  extend  from  the  external  to  the  internal  canthus. 
The  palpebral  conjunctiva  is  more  or  less  rich  in  leukocytes  and  small  lymphatic  nodules  which 
occasionally  furnish  the  starting-point  for  trachoma.  It  is  so  firmly  adherent  to  the  tarsal  plate 
that  there  is  no  pathologic  condition  in  which  it  is  separated  from  this  structure.  This  is  in 
marked  contrast  to  the  ocular  conjunctiva,  which  is  so  loosely  attached  to  the  eyeball  that  it  may 
be  pinched  up  into  folds  with  the  forceps;  it  is  easily  separated  from  the  eyeball  by  inflammations 
and  hemorrhages  and  occasionally  overhangs  the  corneal  margin. 

The  lachrymal  gland,  situated  in  the  lachrymal  fossa  of  the  frontal  bone,  consists  of  a  larger 


Fig.  1 6. 


Superior  longitudinal  sinus 
Cerebral  vein 


ebri 


Orbital   plate  of 
frontal  bone 
M,   levator  palpebrae 
M.   rectus  superioris 

M.  obliquus  superioris 

Lachrymal  gland 

M.  rectus  externus 

M.  rectus  internus 

M.  obliquus  infe)  ion's 
M.  rectus  inferioris 

Hiatus  semilunaris 


M.  masseter 
Internal  maxillary  aitery 


Tongue 
M.  buccinator 


M.  geniohyoglossus 


Scalp 

Subepicranial  connective 

tissue 
Frontal  bone 

Dura  mater 
Frontal  lobe 


Superficial   temporal 

artery  and  vein 
M.   temporalis 

Deep  temporal  artery  and  vein 
Olfactory  tract 
Optic  papilla 
Ethmoidal  cells 

Eye-ball 


Middle  turbinated  bone 


Infra-orbital  artery 

and  nerve 
Nasal  cavity 

Inferior  turbinated  bone 
Maxillary  sinus 


Htird  palate 
Tunica  mucosa 
Dorsum   linguae 

Facial  artery 
Vestibulum  oris 
Submaxillary  duct 
Lingual  nerve 
Ranine  artery 
Sublingual  gland 


THE    ORBITAL    CAVITY. 


45 


superior  portion  and  of  a  smaller  inferior  portion,  the  latter  not  always  being  sharply  defined. 
The  convex  surface  of  the  gland  is  in  relation  with  the  fossa,  and  the  anterior  border  of  the  gland 
extends  to  the  supraorbital  margin,  so  that  it  may  be  readily  exposed  above  the  external  canthus 
by  an  incision  along  the  supraorbital  margin  dividing  the  skin,  the  orbicularis  palpebrarum 
muscle,  and  the  tarsal  ligament.  The  lachrymal  gland  may  also  be  reached  through  the  fornix 
conjunctivae  without  making  a  cutaneous  incision.  The  lachrymal  ducts,  about  ten  in  number, 
empty  into  the  fornix  above  the  external  canthus  of  the  eye.  The  two  lachrymal  canals,  the  in- 
ferior being  somewhat  broader  and  shorter  than  the  superior,  are  about  0.5  millimeter  in  diameter, 
but  they  are  so  elastic  that  they  may  be  dilated  with  sounds  to  three  times  this  diameter.  They 
commence  at  the  inner  ends  of  the  palpebral  margins  in  the  puncta  lachrymalia,  which  the  reader 
may  easily  see  in  his  own  eye  with  the  aid  of  a  mirror.  These  puncta  are  situated  at  the  summit 
of  small  elevations  known  as  the  lachrymal  papillas.  They  dip  into  the  lacus  lachrymalis  and 
take  the  tears  from  this  situation  to  the  lachrymal  sac,  which  is  lodged  in  a  deep  groove  formed 
by  the  lachrymal  bone  and  the  nasal  process  of  the  superior  maxillary.  The  upper  portion  of  the 
lachrymal  sac  is  in  intimate  relation  with  the  lower  end  of  the  frontal  sinus,  thus  explaining  the 
occasional  occurrence  of  purulent  dacryocystitis  in  purulent  inflammations  of  the  frontal  sinus. 
The  nasal  duct,  a  direct  continuation  of  the  lachrymal  sac,  runs  downward  in  a  canal  of  the 
same  name  to  empty  into  the  inferior  meatus  of  the  nose.  The  direction  of  this  duct  is  not 
directly  downward,  but  somewhat  inward  and  backward,  being  subject  to  slight  variation. 

The  most  important  part  of  the  orbital  contents,  the  eyeball,  does  not  completely  fill  the  orbital 
cavity.  It  lies  in  the  anterior  broad  portion  of  the  orbit  in  such  a  way  that  when  the  individual 
looks  straight  ahead,  the  center  of  the  cornea  is  in  a  vertical  line  connecting  the  middle  points  of 
the  upper  and  lower  orbital  margins.  The  optic  nerve,  entering  at  the  optic  foramen,  runs  ap- 
proximately in  the  long  axis  of  the  orbit  to  the  posterior  surface  of  the  eyeball,  which  it  reaches 
some  millimeters  to  the  nasal  side  of  the  posterior  pole.  During  this  course,  the  nerve,  surrounded 
by  a  sheath  of  dura  and  pia  mater,  does  not  run  in  a  straight  line,  but  in  certain  slight  curves  which 
vary  even  in  carefully  made  sections.  These  small  curves  are  probably  not  of  much  importance 
to  the  physician,  but  they  may  be  important  to  the  physiologist.  With  good  fortune,  a  horizontal 
frozen  section  may  strike  both  nerves  in  the  same  plane  and  show  their  entire  course  (Fig.  17). 

The  space  between  the  eyeball,  the  optic  nerve,  and  the  periorbita  is  filled  by  the  orbital  fat, 
the  voluntary  muscles  of  the  eye,  the  blood-vessels,  and  the  nerves. 

The  orbital  fat  is  separated  from  the  eyeball  by  the  capsule  of  Tenon,  forming  a  socket  in 
which  the  motions  of  the  eyeball  take  place.  Between  the  capsule  and  the  bulbus  oculi  there 
is  a  capillary  lymphatic  space,  the  spatium  interjasciale  (Tenoni)  or  space  of  Tenon.  In  the 
vicinity  of  the  cornea  the  capsule  of  Tenon  gradually  disappears  in  the  connective  tissue  overlying 
the  sclerotic  coat.  The  ocular  muscles  must  consequently  perforate  this  capsule  of  Tenon  before 
they  become  inserted  into  the  sclerotic  coat ;  the  same  is  true  of  the  vessels  and  nerves  which  enter 
the  eyeball  behind  the  equator.  [To  reach  the  insertions  of  the  muscles  into  the  sclerotic  it  is 
therefore  necessary  to  cut  two  layers,  the  ocular  conjunctiva  and  the  capsule  of  Tenon. — Ed.] 

All  of  the  muscles  0}  the  eye  (see  Figs.  16  and  17),  with  the  exception  of  the  inferior  oblique, 
arise  from  the  circumference  of  the  optic  foramen.  As  they  pass  forward  they  form  a  partly 
open  hollow  pyramid,  the  base  of  which  is  situated  at  about  the  equator  of  the  eyeball.     The 


46  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

superior,  external,  inferior,  and  internal  recti  muscles  are  inserted  into  the  corresponding  portions 
of  the  bulbus  oculi  (globe  of  the  eye)  in  front  of  the  equator  by  means  of  flat,  white,  glistening 
tendons,  in  such  a  way  that  the  average  distance  between  the  insertion  into  the  sclera  and  the 
corneal  margin  is  7.7  millimeters  for  the  superior,  6.9  millimeters  for  the  external,  6.5  millimeters 
for  the  inferior,  and  5.5  millimeters  for  the  internal  rectus.  The  long  tendon  of  the  superior 
oblique  muscle  is  fixed  by  its  pulley  to  the  fovea  trochlearis  and  passes  beneath  the  superior  rectus 
to  be  inserted  behind  the  equator  upon  the  upper  surface  of  the  eyeball  between  the  attachments 
of  the  superior  and  external  recti.  The  inferior  oblique  muscle  arises  from  the  floor  of  the  orbit 
behind  the  central  portion  of  the  infraorbital  margin.  It  runs  outward  and  backward  beneath 
the  inferior  rectus  and  is  attached  posterior  to  the  equator,  at  a  point  midway  between  the 
insertion  of  the  external  rectus  muscle  and  the  point  of  entrance  of  the  optic  nerve.  The  levator 
palpebrce  superioris  almost  completely  covers  the  superior  rectus  and  its  fibers  radiate  to  the  tarsal 
cartilage  of  the  upper  lid.  [It  arises  from  the  under  surface  of  the  lesser  wing  of  the  sphenoid. — 
Ed.]  The  tendons  perforate  the  capsule  of  Tenon  after  the  fascia  of  the  muscles  has  become 
adherent  to  this  structure.  It  consequently  follows  that  the  tendinous  insertions  of  the  muscles 
into  the  eyeball  may  be  divided  from  the  conjunctival  sac  (in  strabismus  operations),  without 
fearing  that  a  complete  retraction  of  the  muscles  will  take  place.  [After  enucleation  of  the  eye 
the  muscles  through  this  attachment  to  the  capsule  of  Tenon  may  provide  motion  to  the  stump 
and  thus  to  an  artificial  eye. — Ed.] 

The  ophthalmic  artery,  the  only  branch  of  the  internal  carotid  not  supplying  the  brain,  is 
given  off  from  the  last  curve  of  the  carotid,  the  convexity  of  the  curve  being  anterior  (see  page  34). 
It  passes  into  the  orbit  through  the  optic  foramen,  in  company  with  the  optic  nerve,  and  is  situated 
outside  and  below  this  structure.  The  artery  then  runs  inward  between  the  optic  nerve  and  the 
superior  rectus  and  along  the  superior  oblique  muscle.  It  escapes  from  the  orbit  beneath  the 
trochlea  and  divides  into  its  terminal  branches,  the  dorsalis  nasi  (anastomosing  with  the  angular 
artery,  the  terminal  branch  of  the  facial)  and  the  frontal  artery.  The  other  branches  of  the 
ophthalmic  are:  the  lachrymal,  to  the  lachrymal  gland  and  externally  to  the  lids;  the  supra- 
orbital, the  largest  branch,  situated  just  beneath  the  periorbita  and  passing  out  of  the  orbit 
through  the  supraorbital  notch  or  foramen;  the  anterior  and  posterior  ethmoidal,  running  through 
the  foramina  of  the  same  name;  the  important  arteries  of  the  interior  of  the  eye,  the  long  and  short 
ciliary;  and  the  small  important  terminal  branch,  the  arteria  centralis  retince.  The  vessel  also 
•gives  off  muscular  branches. 

The  veins  of  the  orbital  cavity,  occasionally  leading  to  exophthalmos  as  a  result  of  venous 
stasis,  unite  to  form  two  pronounced  trunks.  The  superior  ophthalmic  vein,  the  larger  of  the  two, 
is  situated  at  first  at  the  inner  side  of  the  orbit;  it  passes  outward  between  the  optic  nerve  and  the 
superior  rectus  and  empties  into  the  cavernous  sinus  through  the  sphenoidal  fissure.  At  the 
inner  canthus  this  vessel  anastomoses  with  the  angular  vein  (from  the  facial)  and  with  the  frontal 
vein  (see  Plate  2).  The  inferior  ophthalmic  vein  arises  in  the  central  portion  of  the  floor  of  the 
orbit  and  empties  partly  through  the  sphenoidal  fissure  into  the  cavernous  sinus  and  partly 
through  the  spheno-maxillary  fissure  into  the  region  drained  by  the  facial  vein.  This  inferior 
ophthalmic  vein  may  be  absent.     Valves  are  not  present  in  any  of  these  veins. 

The  nerves  of  the  orbit,  in  addition  to  the  optic,  are  the  sensory  first  division  of  the  trifacial, 


THE    ORBITAL    CAVITY. 


47 


the  ophthalmic,  with  its  three  branches,  and  the  nerves  supplying  the  ocular  muscles — the  oculo- 
motor, the  trochlear,  and  the  abducent.     All  these  nerves,  except  the  optic,  enter  the  orbit  through 


Eyeball 

•   ^k 

M.  rectus 

internus 

M.  rectus— 

externus 

Dural  sheath  of 

optic  nerve 

M.  temporalis 

\\~~wJf  /* 

Optic  nerve i 

yfff 

Internal  carotid 

artery                 J 
Optic  chiasm-""^ 

Oculomotor M 

nerve             1  ' 

w'jm 

Cerebral fljfl 

peduncle"  1 

Aquacductus-  IS- 
cerebri 

Corpora      _^B 
quadrigemina  "■ 

-  -  — 

Straight  sinus --B1. 

m 

'Dorsum  nasi 


Septum  nasi 

cartilagineum 


Zygomatic  pro- 
cess 

— ^"-* Ethmoidal  cells 

Periorbita 
Great  wing  of 
sphenoid  bone 


Sphenoid  sinus 


Squamous  por- 
tion of  temporal 
bone 


Cut  surface  of 
falx  cerebri  - 


Superior  longi- 
tudinal sinus 

Occipital  bone 
Scalp 


Fig.  17. — A  horizontal  section  of  the  head  in  the  plane  of  the  palpebral  fissures  (frozen  section).  The  plane  of 
section  passes  through  the  orbits  in  such  a  way  as  to  show  the  entire  length  of  the  optic  nerves  as  well  as  a  portion  of 
the  optic  chiasm.  The  cerebellum  lies  in  the  posterior  cerebral  fossa  and  is  covered  in  by  the  tentorium  cerebelli,  which 
has  been  left  intact.  In  the  incisura  tentorii  may  be  seen  the  cross-sections  of  the  two  cerebral  peduncles;  the  entire 
cerebrum  has  been  removed. 


48  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

the  sphenoidal  fissure.  The  most  superficial  nerve,  and  the  one  first  exposed  beneath  the  perior- 
bita after  chiseling  open  the  orbit  from  the  frontal  cavity,  is  the  frontal  branch  (upon  the  levator 
palpebral  superioris)  of  the  ophthalmic  nerve,  which  has  already  been  mentioned  in  the  section 
upon  the  scalp.  The  second  branch  of  the  ophthalmic  nerve,  the  lachrymal  (to  the  lachrymal 
gland),  is  also  superficial,  while  the  third  branch,  the  nasal  nerve,  passes  internally  between  the 
posterior  portion  of  the  superior  rectus  muscle  and  the  optic  nerve,  gives  off  the  long  ciliary  nerves 
to  the  eyeball,  and  divides  into  the  infratrochlear,  the  anterior  ethmoidal,  and  the  posterior 
ethmoidal  nerves.  The  trochlear  nerve  runs  along  the  upper  and  inner  portion  of  the  orbit  to  the 
superior  oblique  muscle.  The  abducent  nerve,  situated  to  the  outer  side  of  the  optic  nerve  in 
association  with  the  nasal  nerve,  passes  to  the  external  rectus  muscle.  All  of  the  remaining 
ocular  muscles  are  supplied  by  the  oculomotor  nerve,  which  divides  before  it  enters  the  orbit 
into  a  superior  division,  for  the  levator  palpebral  superioris  and  the  superior  rectus,  and  into  an 
inferior  division,  for  the  internal  rectus,  the  inferior  rectus,  and  the  inferior  oblique. 

The  small  ciliary  ganglion  is  situated  in  the  posterior  portion  of  the  orbit  external  to  the  optic 
nerve.  Its  roots  and  branches  should  be  reviewed  in  a  systematic  anatomy.  We  also  find  within 
the  orbit,  but  outside  of  the  periorbita,  two  branches  of  the  superior  maxillary  division  of  the 
trifacial,  the  small  temporomalar  nerve  and  the  important  infraorbital  nerve. 


THE  NASAL  CAVITY. 

The  nasal  cavities  are  paired  structures,  the  bony  framework  of  which  is  open  anteriorly  at 
the  apertura  pyrijormis  (anterior  nares)  and  posteriorly  at  the  choana  (posterior  nares).  The 
apertura  pyriformis  is  formed  by  the  lower  margin  of  the  nasal  bone  and  by  the  margin  which 
separates  the  facial  from  the  nasal  surface  of  the  superior  maxilla.  The  choanae  are  bounded  by 
the  posterior  edge  of  the  vomer,  by  the  pterygoid  process  of  the  sphenoid,  and  by  the  horizontal 
plate  of  the  palate  bone. 

The  roof  of  the  bony  fossa  is  formed  by  the  nasal  bone,  by  the  thin  cribriform  plate  of  the 
ethmoid  transmitting  the  olfactory  filaments,  and  posteriorly  by  the  body  of  the  sphenoid,  whose 
anterior  as  well  as  inferior  surfaces  project  into  the  nasal  cavity,  diminishing  the  vertical  diameter 
of  this  cavity  to  the  extent  of  the  vertical  diameter  of  the  body  of  the  sphenoid.  The  sphenoid 
body  contains  the  two  sphenoidal  sinuses.  A  pointed  instrument  may  be  driven  into  the  brain 
from  the  nasal  cavity,  through  the  cribriform  plate  of  the  ethmoid,  without  using  a  great  deal  of 
force. 

The  floor  o]  the  nasal  fossa,  when  the  individual  looks  straight  ahead,  slopes  gently  down- 
ward and  backward  and  is  slightly  concave  from  side  to  side.  It  consists  of  the  palatal  process 
of  the  superior  maxilla  and  of  the  horizontal  plate  of  the  palate  bone,  which  are  united  in  the 
transverse  palatine  suture. 

The  inner  wall,  or  the  vertical  septum  separating  the  two  nasal  fossas,  is  usually  deflected 
more  or  less  to  one  side;  this  displacement  is  occasionally  so  marked  that  the  affected  nasal 
cavity  is  greatly  narrowed  or  even  obliterated.  These  deflections  of  the  septum  are  due  to  dis- 
turbances of  growth,  and  are  to  be  differentiated  from  those  occasionally  produced  by  tumors, 
which  grow  into  the  nasal  fossa  from  the  base  of  the  skull  through  the  cribriform  plate  of  the 


THE    NASAL   CAVITY.  49 

ethmoid  and  dislocate  the  septum  toward  the  healthy  side.  The  osseous  septum  is  composed 
of  the  perpendicular  plate  of  the  ethmoid  bone  and  of  the  vomer.  The  alae  of  the  vomer  articu- 
late with  the  lower  surface  of  the  body  of  the  sphenoid;  its  lower  border  rests  upon  the  nasal 
crest  of  the  hard  palate,  the  posterior  free  border  divides  the  two  choanae,  and  the  superior  portion 
of  the  anterior  border  of  the  bone  is  united  with  the  perpendicular  plate  of  the  ethmoid.  An- 
teriorly the  septum  is  completed  by  the  triangular  cartilage. 

The  structure  of  the  outer  wall  of  the  nasal  fossa  is  complicated  by  the  presence  of  the  tur- 
binated bones  and  of  the  orifices  of  the  numerous  accessory  cavities  (see  Fig.  19).  Above  and  in 
front  are  the  nasal  bone,  the  nasal  process  of  the  superior  maxilla,  and  the  lachrymal  bone; 
behind  these  are  the  nasal  surface  of  the  superior  maxilla  with  the  large  orifice  of  the  antrum  of 
Highmore,  the  lateral  masses  of  the  ethmoid  with  the  superior  and  middle  turbinated  bones,  and, 
still  further  posterior,  the  vertical  plate  of  the  palate  bone  and  the  pterygoid  process  of  the  sphe- 
noid. The  inferior  turbinated  bone,  articulating  with  the  inferior  turbinated  crests  of  the  superior 
maxillary  and  palate  bones,  is  an  independent  bone  (one  of  the  six  paired  bones  of  the  face). 

The  inferior  meatus  is  situated  between  the  floor  of  the  nasal  cavity  and  the  inferior  turbi- 
nated bone;  the  middle  meatus  is  between  the  inferior  and  middle,  and  the  superior  meatus  is 
between  the  middle  and  superior  turbinated  bones.  The  meatuses  communicate  with  the  main 
portion  of  the  nasal  cavity  beneath  the  overhanging  turbinated  bones;  they  run  from  before  back- 
ward, and  are  shorter  and  narrower  as  we  pass  from  below  upward. 

The  nasal  cavity  communicates  with  the  mouth  through  the  bony  anterior  palatine  canal, 
which  commences  as  a  double  foramen  on  the  nasal  floor,  one  foramen  being  situated  to  either 
side  of  the  nasal  septum,  and  ends  as  a  single  foramen  in  the  anterior  portion  of  the  oral  surface 
of  the  hard  palate.  The  canal  for  the  nasal  duct  passes  down  from  the  orbit  to  open  into  the 
inferior  meatus.  The  nasal  fossa  communicates  with  the  cranial  cavity  through  the  numerous 
foramina  in  the  cribriform  plate  of  the  ethmoid  (for  the  olfactory  filaments)  and  with  the  spheno- 
maxillary fossa  through  the  spheno-palatine  foramen  (for  the  spheno-palatine  artery  and  the 
superior  nasal  and  naso-palatine  nerves). 

The  wide  orifice  of  the  antrum  of  Highmore  in  the  isolated  superior  maxillary  bone  is  con- 
siderably encroached  upon  during  life  by  the  articulation  and  imposition  of  neighboring  bones. 
These  bones  are  the  perpendicular  plate  of  the  palate  bone,  the  inferior  turbinated  bone  with  its 
maxillary  process,  and  the  uncinate  process  of  the  ethmoid. 

[Above  and  from  before  backward  the  outer  osseous  wall  is  made  up  by  the  nasal  bone, 
nasal  process  of  the  superior  maxilla,  lachrymal  bone,  lateral  mass  of  ethmoid,  and  the  orbital 
process  of  the  vertical  plate  of  the  palate  bone.  Below  and  from  before  backward  the  outer  wall 
is  made  up  of  the  nasal  aspect  of  the  body  of  the  sphenoid,  the  vertical  plate  of  the  palate,  and 
the  inner  plate  of  the  pterygoid  process  of  the  sphenoid  bone. 

The  nasal  aspect  of  the  body  of  the  superior  maxilla  presents  the  opening  leading  into  the 
antrum  of  Highmore  (superior  maxillary  sinus).  This  opening  is  partially  closed  in  by  bone 
and  mucous  membrane.  The  lower  half  is  completely  closed  by  the  maxillary  process  of  the  in- 
ferior turbinated  and  the  maxillary  process  of  the  vertical  plate  of  the  palate  bone.  Above,  the 
antral  opening  is  partially  closed  by  the  uncinate  process  of  the  ethmoid  bone  passing  down 
from  before  backward  in  a  curved  direction  to  articulate  with  the  ethmoid  process  of  the  inferior 


50  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

turbinate  bone.  This  divides  the  upper  portion  of  the  antral  opening  into  two  parts,  of  which 
the  posterior  half  is  usually  closed  in  by  mucous  membrane,  while  the  anterior  part  presents  the 
normal  opening  leading  into  the  superior  maxillary  sinus.  These  openings  lead  from  the  antrum 
into  the  middle  meatus. — Ed.] 

The  skin  oj  the  nose,  though  movable  upon  the  underlying  bones,  is  so  firmly  adherent  to  the 
nasal  cartilages  that  cutaneous  defects  cannot  be  closed  by  approximating  the  edges  of  the  wound, 
and  the  scars  following  such  defects  do  not  undergo  very  marked  contraction.  In  the  vicinity  of 
the  alae  the  skin  is  particularly  rich  in  sebaceous  glands,  which  through  the  retention  of  their 
secretion  and  the  occasional  appearance  of  the  demodex  folliculorum  may  lead  to  the  formation 
of  "black-heads"  (comedones).  At  the  nostril  the  skin  with  its  hairs  (vibrissa?)  and  sebaceous 
glands  is  continued  into  the  nasal  cavity,  the  glands  and  hair  gradually  disappearing,  but  the 
epidermic  character  being  maintained  as  far  as  the  region  of  the  anterior  nares.  This  portion  of 
the  nasal  cavity  is  known  as  the  vestibulum  nasi. 

The  olfactory  region  is  the  only  portion  of  the  nasal  mucous  membrane  containing  olfactory 
cells;  it  covers  the  superior  turbinated  bone,  occasionally  a  small  region  of  the  middle  turbinated 
bone,  and  the  opposite  portion  of  the  septum.  The  mucous  membrane  of  the  respiratory  region 
is  devoid  of  a  submucous  layer  and  adheres  directly  to  the  periosteum.  It  is  predisposed  to 
swellings  on  account  of  the  cavernous  tissue,  which  is  especially  developed  upon  the  free  borders 
of  the  inferior  and  middle  turbinated  bones.  The  mucous  membrane  also  lines  the  accessory 
cavities,  becoming  much  thinner  and  losing  almost  all  of  its  glands  as  it  passes  in  through  their 
orifices. 

There  are  no  large  arteries  of  surgical  importance  within  the  nasal  cavity.  Marked  hem- 
orrhages, usually  of  capillary  or  venous  origin,  are  consequently  controlled  by  plugging.  The 
largest  artery  is  the  sphenopalatine,  a  branch  of  the  internal  maxillary,  which  passes  from  the 
spheno-maxillary  fossa  through  the  spheno-palatine  foramen  to  the  outer  and  inner  walls  of  the 
nasal  chamber.  The  other  arteries  are  the  small  anterior  and  posterior  ethmoidal  (from  the 
ophthalmic)  and  the  anastomoses  of  the  facial  and  of  the  palatine  arteries  in  the  region  of  the  alae 
of  the  nose. 

The  veins  of  the  nasal  cavity  are  particularly  well  developed;  they  form  superficial  and  deep 
plexuses  as  well  as  the  cavernous  tissue  upon  the  turbinated  bones.  The  ethmoidal  veins  (accom- 
panying the  arteries  of  the  same  name)  empty  into  the  superior  longitudinal  sinus.  The  veins 
of  the  nose  are  also  connected  with  the  veins  of  the  cranial  cavity  through  the  cribriform  plate  of 
the  ethmoid;  the  foramen  caecum  transmits  an  emissary  vein  in  the  child  but  not  in  the  adult. 
The  connection  of  the  veins  of  the  nasal  cavity  with  those  of  the  brain  explains  the  relief  afforded 
in  a  severe  headache  after  bleeding  from  the  nose. 

The  nerves  of  the  nasal  cavity,  disregarding  those  of  special  sense,  the  olfactory  filaments 
(see  page  21),  are  the  sensory  nerves  supplying  the  mucous  membrane  and  proceeding  from  the 
first  and  second  divisions  of  the  trifacial.  The  nasal  nerve  is  given  off  from  the  ophthalmic  or 
first  division  of  the  trifacial,  passes  through  the  anterior  ethmoidal  foramen,  pursues  a  short 
subdural  course  in  the  cranial  cavity,  and  runs  through  the  cribriform  plate  of  the  ethmoid  toward 
the  vestibulum  nasi;  it  gives  off  an  external  branch  which  reaches  the  skin  of  the  nose  below  the 
lower  border  of  the  nasal  bone.     The  main  nervous  filaments  come  from  the  spheno-palatine 


THE    NASAL   CAVITY. 


51 


ganglion  in  the  spheno- maxillary  fossa  and  pass  through  the  spheno-palatine  foramen  as  the 
superior  nasal  and  naso- palatine  nerves  to  the  lateral  and  median  walls  of  the  nasal  cavity.  The 
naso-palatine  nerve  runs  upon  the  septum  as  far  as  the  foramen  of  Scarpa.  When  the  surgeon, 
operates  in  this  deep  region,  he  has  other  things  to  think  about  than  this  little  nerve. 

The  maxillary  sinus  or  antrum  0}  Highmore  is  the  largest  of  the  accessory  cavities  of  the  nose. 
It  is  separated  from  the  orbit  by  the  orbital  plate  of  the  superior  maxilla  and  extends  posteriorly, 
entirely  filling  the  body  of  this  bone.  Upon  the  floor  of  the  sinus  the  sockets  of  the  molar  teeth 
frequently  produce  elevations,  or  the  apex  of  the  tooth-socket  opens  directly  into  the  antrum  so 
that  the  tip  of  the  root  is  covered  only  by  the  mucous  membrane  of  the  sinus.     This  is  the  situation 


Zygoma. 


Pterygoid  fossa 
Tuber  maxillare 


Internal  pterygoid  plate 
of  sphenoid  bone 


Hamular  process  of 
sphenoid  bone 


Orbital  plate  of  frontal  bone 


-Nasal  bone 

Os  planum  of  ethmoid  bone 
Lachrymal  bone 
Nasal  process  of  superior 
maxilla 


Communication  of  maxillary 
sinus  with  nasal  cavity 


First  bicuspid 


Inner  socket  of  second  molar 


Socket  of  second  bicuspid 
Inner  socket  of  first  molar 


Fig.  18. — A  portion  of  the  skull  in  which  the  outer  wall  of  the  maxillary  sinus  has  been  removed  in  order  to  show 
its  communication  with  the  nasal  cavity  and  the  relations  of  the  dental  alveoli  to  the  floor  of  the  sinus.  The  alveoli  have 
been  perforated  from  below. 

in  which  diseases  of  the  roots  of  the  back  teeth  occasionally  lead  to  inflammations  and  purulent 
collections  in  the  maxillary  sinus.  Since  the  orifice  of  the  sinus  is  situated  so  high  up  (see  Figs. 
15  and  16)  that  it  is  inadequate  for  drainage,  in  such  cases  the  sinus  must  be  opened  at  its  most 
dependent  portion.  A  tooth  is  extracted  and  the  floor  of  the  sinus  perforated  through  the  al- 
veolus to  allow  of  the  evacuation  of  the  contents  of  the  sinus.  Fig.  18  shows  the  relation  of  the 
sockets  of  the  back  teeth  to  the  floor  of  the  maxillary  sinus,  the  outer  wall  of  which  has  been 
removed  by  the  chisel.  It  will  be  seen  that  the  inner  sockets  of  the  first  and  second  molar  teeth 
are  the  ones  most  favorably  situated  for  the  performance  of  this  operation. 


l-U\S 


52  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  19. — The  lateral  wall  of  the  left  nasal  cavity.  Almost  the  entire  middle  turbinated  bone  has  been  excised 
in  order  to  expose  the  structures  and  orifices  situated  beneath  it.  A  piece  has  been  removed  from  the  anterior  portion 
of  the  inferior  turbinated  bone.  The  original  borders  of  the  turbinated  bones  are  indicated  by  dotted  lines.  The  superior 
turbinated  bone  is  intact.     The  orifices  of  the  left  sphenoidal  and  frontal  sinuses  are  shown  by  arrows. 

Fig.  20. — Sublingual  region,  shown  on  a  median  section.  The  mucous  membrane  has  been  divided  and  the 
tongue  is  turned  downward. 

Another  method  of  opening  the  sinus  is  to  go  through  its  inner  wall,  i:  e.,  through  the  thin 
outer  wall  of  the  nasal  fossas  below  the  inferior  turbinated  bone  (see  Figs.  15  and  19).  An  in- 
cision may  be  made  through  the  cheek  and  the  anterior  wall  of  the  sinus  chiseled  open  below  the 
infraorbital  foramen.  The  fourth  method  of  attacking  the  sinus  is  to  chisel  through  its  anterior 
wall  above  the  alveolus  from  the  vestibulum  oris  [i.  e.,  through  the  canine  fossa  external  to  the 
elevation  caused  by  the  canine  tooth. — Ed.]  (see  Fig.  16).  The  orifice  of  the  maxillary  sinus  is 
situated  beneath  the  middle  turbinated  bone  and  cannot  be  distinctly  seen  until  this  structure  has 
been  removed.  Attempts  to  reach  this  concealed  orifice  in  the  living  are  usually  fruitless.  [The 
normal  opening  into  the  maxillary  sinus  is  usually  found  near  the  most  dependent  portion  of  the 
hiatus  semilunaris  and  under  cover  of  the  middle  turbinated  bone. — Ed.]  In  addition  to  the  main 
orifice,  there  is  frequently  an  accessory  opening  at  or  beneath  the  margin  of  the  middle  turbinated 
bone  (see  Fig.  19).  Since  the  inner  wall  of  the  maxillary  sinus  is  formed  by  only  a  thin  osseous 
lamina  and  partly  by  mucous  membrane  alone,  it  will  be  readily  understood  that  tumors  arising 
within  the  sinus  (carcinomata,  for  example)  grow  inward  into  the  nasal  fossa.  The  roof  is  thin 
also  and  may  be  perforated  by  tumors  originating  in  the  sinus;  these  tumors  may  grow  into  the 
orbit  and  dislocate  the  eyeball.  In  such  cases  the  infraorbital  nerve  running  in  the  roof  of  the 
sinus  may  be  affected  and  give  rise  to  neuralgic  symptoms.  Such  symptoms  may  also  be  pro- 
duced by  a  fracture  of  the  superior  maxilla,  in  which  the  air  from  the  sinus  may  gain  access  to  the 
subcutaneous  tissues  of  the  cheek  or  to  the  orbital  cavity  and  cause  emphysema.  Tumors  of  the 
maxillary  sinus  may  also  displace  the  anterior  wall  of  the  cavity  and  grow  toward  the  face.  If  they 
extend  posteriorly,  they  reach  the  spheno-maxillary  fossa,  and  from  here  they  may,  under  certain 
circumstances,  invade  the  pharynx  or  grow  into  the  cranial  cavity  through  the  base  of  the  skull. 

The  frontal  sinuses  are  also  of  importance  to  the  physician.  They  have  been  previously 
described  upon  page  19.  Fig.  4  shows  the  right  frontal  sinus,  which  has  been  opened  from  the 
forehead  and  in  the  depths  of  which  the  entrance  into  the  nasal  fossa  may  be  seen.  In  catarrhal 
inflammations  leading  to  a  closure  of  the  communication  between  the  sinus  and  the  nasal  cavity 
(see  page  19),  the  sinus  may  be  opened  in  this  manner  and  the  contracted  orifice  dilated.  In  the 
nasal  cavity  this  orifice  is  situated  below  the  middle  turbinated  bone  in  the  middle  meatus  at  the 
highest  portion  of  the  slit-shaped  infundibulum  (see  Fig.  19).  During  life  it  is  usually  impossible 
to  probe  this  orifice  from  the  nostril. 

[By  removing  the  anterior  end  of  the  middle  turbinated  bone  it  is  possible  to  pass  a  probe  into 
the  naso-frontal  duct  or  infundibulum.  By  keeping  the  end  of  the  probe  pressing  against  the 
turbinated  side  we  avoid  the  likelihood  of  entering  into  the  anterior  ethmoidal  cells,  which  form 
Y-shaped  diverticuli  leading  from  the  naso-frontal  duct. — Ed.] 

The  paired  sphenoidal  sinuses  are  situated  in  the  most  posterior  portion  of  the  roof  of  the 
nasal  cavity  and  very  close  to  the  base  of  the  skull.  The  superior  wall,  situated  in  the  region  of 
the  sella  turcica,  is  very  thin,  and  tumors  growing  from  the  sinus  may  consequently  easily  extend 


"^  Ct  *z 


JJO 


Fig.  i9. 


Orifice  of  the  middle  and  posterior  ethmoidal  cells 


Superior  turbinated  bone      :  i 


Ethmoid  bone 


Hypophysis  — 

Septum  of  the  sphenoidal 
sinuses  (opened) 
Left  sphenoidal  sinus  

Dura  mater  — - 

Vomer 

Basilar  portion  of  occipital  bone 

Pharyngeal  tonsil 
Pharyngeal  recess 
(Rosenmulleri)       —      - 

Orifice  of  the  Eustachian  tube  -4 

Torus  tubarius     / 

Anterior  arch  of  atlas.  -f*^Hf*-^V^ttr\\ 
Nasal  portion  of  pharynx-  Wr^B 
Odontoid  process  of  axis 
Plica  salpingo- 
pharyngea 
Velum  palatinum 

Bodv  of  the  axis  - 


Jy^^W-ff-U .-      Septum  of  frontal  sinuses 

/j^KLTlll  (opened) 

Left  frontal  sinus 

Nasal  bone 

Transverse  section  of  mucous 
membrane 

Nasal  cartilage 

^^Oi Vestihulum   nasi 

Hard  palate 

M.  orbicularis  oris 


Orifice  of  the  nasal  duct 
:    Orifice  of  the  anterior  ethmoidal  cells 
:  Infundibulum  (region  of  the  orifice  of  the  maxillary  sinus) 
Bulla  ethmoidalis 
Inferior  turbinated  bone 
Accessory  orifice  of  maxillary  sinus 


Hypoglossal  nerve 
Palatoglossal  arch 
Faucial  tonsil 


Lingual  nerve  Submaxillary  duct 


Fie.  20. 


Ranine  artery 
;    Sublingual  salivary  gland 
Sublingual  artery 


Soft  palate 


Uvula 
Palatopharyngeal  arch 


Dorsum  linguae 


Hard  palate 


M.  orbicularis  oris 


Sublingual  caruncle 

Mandible 

M.  Geniohyoglossus 


THE   NASAL   CAVITY.  53 

toward  the  base  of  the  brain.  The  relation  of  the  sinus  to  the  internal  carotid  artery,  which  may 
lead  to  fatal  hemorrhage  from  the  nose,  has  been  already  mentioned  (see  page  31).  The  opening 
of  the  sinus  into  the  nasal  cavity  is  in  the  so-called  spheno-ethmoidal  recess,  behind  and  above 
the  superior  turbinated  bone;  the  orifice  of  the  sinus,  as  is  the  case  in  the  antrum  of  Highmore,  is 
situated  near  its  roof  (see  Fig.  19). 

The  air-cells  of  the  lateral  masses  of  the  ethmoid  bone,  which  occupy  the  upper  portion  of  the 
outer  wall  of  the  nasal  fossas  (see  Figs.  15,  16,  and  17),  have  previously  been  described  (see 
page  43)>  and  it  will  readily  be  understood  that  this  spongy  partition  between  the  orbital  and 
nasal  cavities  may  easily  disappear  as  the  result  of  the  pressure  of  tumors  growing  into  the  orbit 
from  the  ethmoidal  cells  or  from  the  nasal  fossa.  The  openings  leading  to  the  ethmoidal  cells 
are  to  be  found  upon  the  outer  wall  of  the  nasal  fossa.  In  Fig.  19  the  middle  turbinated  has 
been  removed  close  to  its  attachment,  so  that  the  long  slit-like  infundibulum  is  exposed,  pass- 
ing from  below  upward  and  forward.  In  the  anterior  portion  may  be  seen  a  probe  which  has 
been  introduced  into  the  frontal  sinus.  The  normal  orifice  of  the  maxillary  sinus  is  situated 
further  posteriorly  in  the  depth  of  the  infundibulum.  The  entrance  to  the  infundibulum  is 
also  designated  as  the  hiatus  semilunaris.  [This  is  incorrect  to  call  the  entrance  to  the 
infundibulum  the  hiatus  semilunaris.  The  hiatus  semilunaris  is  a  groove  in  the  maxillary 
side  of  the  middle  meatus  and  runs  from  the  naso-frontal  duct  above  downward  and  backward; 
and  since  the  anterior  extremity  of  the  middle  meatus  leads  into  the  infundibulum,  the  hiatus 
semilunaris  is  simply  a  recess  from  the  middle  meatus  beginning  at  the  naso-frontal  duct. 
The  anterior  ethmoidal  cells,  as  well  as  the  antral  opening,  open  into  the  middle  meatus 
via  the  hiatus  semilunaris.  Overhanging  the  hiatus  semilunaris  is  a  large  ethmoidal  cell  called 
the  bulla  ethmoidalis.  This  cell  or  cells  open  into  the  middle  meatus  near  the  attached  border 
of  the  middle  tubinated  bone  at  about  its  middle. — Ed.]  The  ethmoidal  cells  usually  bulge  out 
prominently  above  this  hiatus,  forming  the  bulla  ethmoidalis,  and  above  this  is  the  orifice  of  the 
anterior  ethmoidal  cells.  The  middle  and  posterior  ethmoidal  cells,  on  the  contrary,  open  into 
the  superior  meatus.  Sometimes  there  is  still  a  fourth  turbinated  bone  at  a  higher  level,  in 
which  case  the  middle  ethmoidal  cells  may  open  into  the  superior  meatus  and  the  posterior  ones 
between  the  third  and  fourth  turbinated  bones. 

In  Fig.  19  a  portion  of  the  inferior  turbinated  bone  has  also  been  removed,  exposing  the 
orifice  of  the  nasal  duct.  During  life  it  is  accessible  from  the  nostril,  but  it  may  be  probed  from 
above  to  much  better  advantage.  More  worthy  of  note  is  the  fact  that  access  to  the  orifice  of  the 
Eustachian  tube  may  be  gained  through  the  naso-pharynx  (see  Fig.  19  and  Plate  4).  It  lies  0.5 
centimeter  behind  the  posterior  extremity  of  the  inferior  turbinated  bone,  and  is  bounded  poste- 
riorly by  the  torus  tubarius  (an  enlargement  produced  by  the  underlying  tube),  which  may  be 
easily  located  with  a  probe.  The  orifice  of  the  Eustachian  tube  is  six  or  seven  centimeters  from 
the  nostril;  one  centimeter  behind  the  torus  tubarius  is  the  fossa  0}  Rosenmuller  (recessus  infundi- 
buliformis),  which  may  catch  the  end  of  the  probe  when  an  attempt  is  made  to  pass  this  instrument 
from  the  nostril  into  the  tubal  opening  through  the  inferior  meatus. 

A  study  of  the  illustrations  of  the  outer  wall  of  the  nasal  fossa  (see  Figs.  15  to  19,  Plate  4)  will 
show  that  a  chronic  catarrh  may  extend  into  the  Eustachian  tube,  into  the  frontal  and  maxillary 
sinuses,  and  posteriorly  into  the  pharynx.     Tumors  proceeding  from  the  nasal  fossa  may  grow 


54  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

through  the  choanae  toward  the  naso-pharynx  and  into  the  mouth,  into  the  maxillary  sinus,  into 
the  ethmoidal  cells,  into  the  orbit,  and  also  through  the  spheno-palatine  foramen  into  the  spheno- 
maxillary fossa,  whence  they  may  extend  outward  into  the  temporal  fossa  or  through  the  spheno- 
maxillary fissure  into  the  orbit.  Catarrh  or  new-growths  in  the  lateral  wall  of  the  nose  may  lead 
to  disturbances  in  the  vicinity  of  the  nasal  duct. 


THE  ORAL  CAVITY. 

As  the  function  of  the  oral  cavity  is  to  aid  in  the  ingestion  of  food,  it  is  not  surrounded  by  bony 
walls  to  the  same  extent  as  the  nasal  fossas,  but  its  boundaries  are  formed  in  many  places  by 
movable  and  distensible  soft  parts  [see  Fig.  20  a. — Ed.].  The  bony  support  is  furnished  by  the 
hard  palate  and  by  the  inferior  maxillary  bone,  with  their  alveolar  processes  containing  the  teeth. 
The  dividing-line  between  the  mouth  and  the  pharynx  is  known  as  the  isthmus  0}  the  fauces.  It  is 
bounded  below  by  the  sulcus  terminalis  (commencing  at  the  foramen  caecum  and  dividing  the 
dorsum  from  the  root  of  the  tongue)  and  laterally  and  above  by  the  palato-pharyngeal  arch  and 
the  uvula  (see  Fig.  21).  The  roof  of  the  mouth  is  formed  by  the  hard  and  soft  palates;  it  is 
covered  by  a  thick  mucous  membrane,  rich  in  glands  and  fat,  which  is  immovable  on  account  of 
its  firm  attachment  to  the  periosteum.  The  mylohyoid  muscle  is  to  be  looked  upon  as  the  floor 
of  the  mouth,  although  posteriorly  the  oral  contents  seem  to  extend  into  the  neck  without  there 
being  any  sharp  dividing-line.  [Abscesses  or  tumors  above  the  mylohyoid  project  into  the  mouth, 
those  below  present  in  the  neck.— Ed.] 

We  differentiate  the  vestibule  (vestibulum  oris)  from  the  oral  cavity  (cavum  oris). 

The  vestibule  is  a  horseshoe-shaped  cleft  between  the  mucous  membrane  of  the  cheeks  and 
lips  and  the  teeth  (see  Fig.  16).  If  the  finger  is  introduced  into  the  vestibule  and  pushed  back- 
ward, when  the  teeth  are  closed,  it  strikes  upon  the  hard  anterior  margin  of  the  ramus  of  the 
mandible,  and  the  tip  of  the  finger  may  be  passed  into  the  mouth  (cavum  oris)  through  the  space 
between  the  ramus  of  the  mandible  and  the  last  molar  tooth.  If  the  denture  is  perfect,  this  space 
is  the  only  communication  between  the  vestibule  and  the  oral  cavity  (with  the  exception  of  the 
narrow  slits  between  the  teeth),  and,  in  cases  of  trismus,  it  may  be  utilized  for  the  introduction  of 
liquid  food,  if  a  more  favorable  route  has  not  been  furnished  by  the  loss  of  one  or  more  teeth.  If 
the  tip  of  the  index-finger  is  placed  against  the  anterior  border  of  the  ramus  and  the  teeth  are 
firmly  pressed  together  repeatedly,  the  anterior  margin  of  the  contracting  masseter  muscle  may  be 
distinctly  felt.  The  orifice  of  the  parotid  duct  (Stenson's)  is  situated  opposite  to  the  second  upper 
molar  [about  4  mm.  below  the  reflection  of  the  mucous  membrane  from  gums  to  cheek. — Ed.]; 
although  small,  this  duct  may  be  probed  in  the  living  subject  (see  page  41). 

The  marked  elasticity  of  the  lateral  and  anterior  walls  of  the  vestibule  allows  us  to  palpate 
the  rows  of  teeth  throughout  their  entire  extent;  it  also  makes  it  possible  to  recognize  the  altered 
position  of  the  mandible  in  anterior  dislocations  of  this  bone.  Under  certain  circumstances  the 
maxillary  sinus  may  be  opened  through  the  vestibule  (see  page  52). 

The  contents  of  the  oral  cavity,  as  well  as  the  region  between  the  mouth  and  the  pharynx, 
should  be  studied  as  far  as  possible  in  the  mouth  of  the  reader  with  the  aid  of  a  hand-mirror  and 
strong  sunlight.     If  the  tongue  is  raised,  the  fraenum  linguae  may  be  seen  in  the  median  line, 


THE    ORAL    CAVITY. 


55 


and  to  either  side  will  be  observed  the  sublingual  folds,  which  project  in  varying  degrees  in  differ- 
ent subjects.  These  folds  are  due  to  the  upper  margins  of  the  sublingual  glands,  and  to  their 
inner  side  the  submaxillary  ducts  may  be  exposed  (for  the  extraction  of  salivary  calculi,  for  ex- 
ample). The  posterior  portion  of  the  sublingual  gland  lies  upon  the  mylohyoid  muscle,  while  the 
remainder  of  the  gland  is  closely  related  to  the  inner  surface  of  the  mandible,  where  it  produces 
the  sublingual  fossa  of  varying  depth.  The  numerous  invisible  orifices  of  the  gland  are  situated 
upon  the  sublingual  folds.      The  sublingual  gland  frequently  possesses  a  larger  duct  [ductus 


*J- BICUSPID. 

1"  MOLAR 
V  MOLAR- 
S'- MOLAR 


OPENING"^ 
OF  5TEN05 
DUCT. 


LINE  OF 
INCISION)  FO 
PERITONSILL 
AB5CE6SES, 


JUNCTION!   OF 
HARD  AND  SOFT 
PALATES. 

UVULA- 


POSTERIOR 
PILLAR  *s  FAUCES 

FAUCIAL  TONSIL. 


(ANTERIOR. 
TILLAR  os 

FAUCES. 


FRAENUM 
LINGUAE 

OPENINGS  OF    . 
SUBMAXILLARY 
AND  SUBLINGUAL 
GLANDS. 


LINGUAL  VFIN 
FLOOR  OF  MOUTH 

RANINE  ARTERY 


Fig.  20  a. — View  of  adult  mouth  (modified  from  Spalteholz):  M.I.,  Middle  incisor;  L.I.,  lateral  incisor;  C,  canine  tooth; 

1st  Bic,  first  bicuspid  tooth  (Eisendrath). 


major  Rivini  or  duct  of  Bartholin;  according  to  Cunningham,  this  rarely  exists  in  man. — Ed.] 
which  may  unite  with  the  submaxillar)-  duct  or  have  an  independent  orifice.  The  opening  of  the 
submaxillary  duct  (Wharton's)  may  be  recognized,  with  the  naked  eye,  in  the  sublingual  caruncle 
at  the  anterior  extremity  of  the  plica  sublingualis.  [This  duct  and  the  lingual  nerve  lie  beneath 
and  to  the  inner  side  of  the  sublingual  gland;  the  nerve  on  its  way  to  the  tongue  crosses  the  duct 
on  its  inferior  aspect  opposite  the  anterior  border  of  the  hyoglossus  muscle. — Ed.] 


56  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE  4. 
A  median  sagittal  section  of  the  head.     Frozen  section. 

[Congenital  dermoid  cysts  are  frequently  found  in  the  floor  of  the  mouth  at  its  junction  with 
the  base  of  the  tongue.  Retention  cysts  of  the  mucous  glands,  of  Wharton's  duct,  or  the  ducts 
of  the  sublingual  glands  are  called  ranula.  Congenital  cysts  or  fistulas  due  to  incomplete  closure 
of  the  thyroglossal  duct — which  extends  from  the  foramen  caecum  of  the  tongue  to  the  isthmus  of 
the  thyroid — are  always  mesial;  when  developed  from  the  upper  part  of  the  duct,  they  present  in 
the  mouth;  those  arising  from  the  lower  end  present  in  the  neck  below  the  hyoid  bone. — Ed.] 

The  tongue,  the  largest  organ  in  the  mouth,  lies  in  contact  with  the  palate  when  the  mouth 
is  closed.  Its  base  reaches  to  the  epiglottis.  A  median  section  (Plate  4)  shows  that  a  swelling 
of  the  tongue  may  force  the  epiglottis  down  upon  the  entrance  of  the  larynx  in  such  a  manner  that 
tracheotomy  must  be  performed.  It  will  also  be  understood  that  a  paralysis  of  the  muscles  from 
profound  narcosis  will  allow  the  tongue  and  epiglottis  to  fall  back  so  that  respiration  is  interfered 
with. 

The  lingual  artery  supplies  the  tongue  with  blood.  This  vessel  arises  in  the  neck  from  the 
external  carotid  (see  page  64),  passes  above  the  greater  cornu  of  the  hyoid  bone  beneath  the  hyo- 
glossus  muscle,  and,  as  the  ranine  artery,  pursues  a  tortuous  course  in  the  tongue  between  the 
inferior  lingulias  and  geniohyoglossus  muscles.  Although  it  gives  off  the  dorsalis  lingua,  running 
upward  to  the  root  of  the  tongue  to  supply  the  circumvallate  papillas,  the  chief  branch  is  the  sub- 
lingual artery,  which  runs  anteriorly  beneath  the  sublingual  gland  to  reach  the  gums  of  the  incisor 
teeth.  Above  and  to  either  side  of  the  fraenum,  the  artery  is  relatively  superficial,  and  may  be 
caught  by  a  deep  suture  for  the  purpose  of  checking  hemorrhage.  There  are  no  marked  anasto- 
moses between  the  arteries  of  the  two  sides.  In  the  posterior  portion  of  the  tongue  the  artery  is  so 
imbedded  in  the  soft  lingual  musculature  that  it  may  be  impossible  to  control  serious  hemorrhage 
from  operative  procedures  by  ligation  in  the  wound,  and  it  becomes  necessary  to  ligate  the  vessel 
in  the  neck. 

The  lingual  branch  0}  the  glossopharyngeal  nerve  supplies  the  circumvallate  papillas  [that  is, 
the  posterior  part  of  the  tongue,  with  both  gustatory  and  common  sensory  fibers. — Ed.];  it  is  not 
very  large  and  possesses  no  surgical  importance.  The  sensory  nerve  of  the  tongue,  the  lingual 
branch  of  the  inferior  maxillary,  which  also  receives  gustatory  fibers  for  the  fungiform  papillas 
from  the  chorda  tympani,  may  be  easily  exposed  beneath  the  mucous  membrane  at  the  side  of  the 
tongue  in  the  neighborhood  of  the  second  molar  tooth  (see  Fig.  20).  This  nerve  runs  over  the  sub- 
maxillary duct  and  is  also  accessible  in  the  neck  in  the  depths  of  the  submaxillary  triangle  (see 
page  65).  [According  to  Cunningham,  Wolsey,  and  others,  the  nerve  runs  beneath  the  duct. — 
Ed.]  The  motor  nerve,  the  hypoglossal  (see  page  64),  is  more  deeply  situated  [that  is,  from  the 
floor  of  the  mouth. — Ed.]  beneath  the  sublingual  gland.  The  inferior  dental  branch  of  the 
superior  maxillary  division  0}  the  fifth  may  also  be  easily  exposed  in  the  mouth  before  it  enters 
the  inferior  dental  canal  by  means  of  the  same  incision  as  that  for  the  lingual  nerve.  It  may 
also  be  attacked  by  dividing  the  skin  and  masseter  muscle  and  trephining  the  ramus  of  the  jaw. 

The  numerous  lymphatic  vessels  of  the  tongue  lead  to  the  submental  and  submaxillary 
lymphatic  glands,  which  are  consequently  involved  early  in  affections  of  the  tongue. 


Fornix 

Middle  commissure 


Septum  lucidum 


Genu  of  corpus  callosum 
Sphenoidal  sinus 


Frontal  bone 


Vein  of  Galen 

Splenium  of  corpus  callosum 
Parietal  bone 


Inferior  tux 
binated  bone 
Orifice  of  Eu- 
stachian tube 
Ant.  palatine 
canal 


Oral  cavity 


Geniohyoid 

muscle 

Mylohyoid  muscle? 

Hyoid  bon 


Occipital 

bone  .. 

Pineal  gland 

hixd  ventricle 
Lamina 

ftiy— ihiMli  ii  ill i 
Aqueduct  of  , 
Tenio-    [Sylvius 
rium  osrebelli   • 
Fourth  ventricle 


Transverse  sinus 
Clivus 


Pharyngeal  tonsil 
Anterior  arch  of  atlas 


ctiontoici  process 


Palatum  molle 
Soft  palate 

Posterior  arch  of  atlas 


Spinal  «*!*  '*^»iMU• 
Oropharynx    '•  P«^T««i- 


Lig.  t<       Middle  thyrohyoid  ur.- 
Arytenoid  muscles- 
Ventricle  of  larynx. 
Thyroid  cartilage. 


Epiglottis 


•barynx1  Ph^,,«i• 


I  .aryngopl 
,  Sixth  cervical  vertebra 


Cricoid  cartilage 


56 


roUO  to  ubV 
auqioj  k>  rauiiwIqcJ 


TOPOGS*TOIC   AND 

nuaajmm.  >•>  slbbiM 


taj  denude 


c.     R 


ial  glands  i ire  c ilkd 


the  I 

of  the  subl 

of  the  th^f 

the  trnfroid — are'alwaj 

the  j^oath ;  (hose  . 

The  tongue,  th< 
isirlosed.  ,  Its  b: 


oft: 
tfacheotomy  mu.- 


lsliqhoO_ 

-mod 

basis  Is^nilj 


f  nd  narcos 

Qth. 





-  iL"i    I  :     rxh  ■; 


'   (ifcottis 


ill  ah 


sbrUnav  biidTf 

sninisJ 
.cnsgribsup 

to  toubiupl 
cur/l?2]    -oliisl 
Ufodrt93  muh  I E 
shhimv  flnop' 


e  tongue  a 

/-•  the  tor,, 





the  rantne  arteryj 


Lsbiomdq^ 

.  its  junction 


:ajcum  oi 





\ 


\  n  the 

lion  (PJa  \ 

is  djjwn  i.  jitrance  of  the  larynx  in\such  a  manner 


4dc|rstood  that  a  pa  Is  the  mu 

ill  back  so  that  res  I  is  inter: 


■  anod  biomrijH 


artery, 


Thi 
au  of  the  hyoid  bo     ~\th  1 

,  N^  smchul  .qui? 

rortuo;,                                        — ^w    ,n.,j 
_    iossusm  oughitgi  — ^--,;, 


. 


*-■      V •• — — — i — 

WtAntTrnf  vR>  If" 





■i 


lmbed^  ftBgHar  snfl     


in  the  rtecl 

bio?  If.nkj- 


id,  andil 

t 


The  lingual  h    \ 
the  ;  ," ^ 

branch  of  th< 
from  the  chorda  I 
tongue  inlftH!«grrti<T 
maxillary  di 

I.    [Accordi  r~~t 
Ed.]    The  motor  nerve,  th 

mouth.— Ed.]  1. 

e  skin  and  ra 
lymp 


■MHmimM 

•IJKWmO 

ittinonsi 
— I rveofth -/f 


bfovdoiasO 


>rv  fibers  for  th 


. : 


buiai  Jiioyrlolyl/ 


■.})il  biovrfoT^ri)  olbbil/ 
«*4lo2um  l>i'H!:jiyi/. 


.nti'l&iHJ.  from  the 

"Uth  bei 
lingual  nerve.    It  mav 

• 
tal  and  sub: 


Tab .4. 


Commissura  media 
Septum  pellucidum 


Genu  corporis  callosi 
Sinus  sphenoidalis 


V.  cerebri  magna 

Spleninm  corporis  callosi 


Os  parietale 


Os  frontal  e 


Os  ethmoidale 
i  )s  nasale 


Joncha  superior 
Concha  media 


Concha  tnferio 


Ostium  tubae 
analis  incisivusi 


Cavum  oris 


■stibulum  oris 

Mandibula 
M.  peniog-lossus 

A.  geniohyoideus 
M.  mylohyoideus 
Os  hyoides 

Lig.  thyreohyoideum  medium 

Mm.  arytaenoidei 

Ventriculus  laryngis 

Cartil.  thyreoidea 

Cart,  cricoidea 


s  occipitale 
landula  pinealis 
fentriculus  tertius 
amina  quadrigem. 

Aquaeduct  us  cerebri 
entorium  cerebelli 
entriculus  quartus 
Pons 
Sinus  transrersus 
Clivus 


Tonsilla   pharyngea 
Arcus  ant.  atlantis 


Dens  epistrophei 

Palatum  molle 

Arcus  posterior  atlantis 


Medulla  spinalis 
Pars  oralis  pharyngis 

Epiglottis 

Pars  laryngea  pharyngis 
Vertebra  cervicalis  VI 


THE    ORAL    CAVITY.  57 

In  the  posterior  portion  of  the  oral  cavity  may  be  seen  the  soft  palate  with  the  uvula,  the 
potato- glossal  and  potato- pharyngeal  arches,  and,  between  the  latter  structures,  the  more  or  less 
prominent  jaucial  tonsil,  which  is  frequently  the  seat  of  simple  or  diphtheric  inflammation.  Both 
the  soft  and  the  hard  palates  receive  their  blood  from  the  terminal  branches  of  the  descending 
palatine  artery,  which  is  given  off  from  the  internal  maxillary  in  the  spheno-maxillary  fossa,  passes 
downward  through  the  posterior  palatine  canal,  and  makes  its  exit  at  the  posterior  palatine  fora- 
men. [In  repairing  cleft  palate  it  is  necessary,  in  order  to  avoid  hemorrhage  and  to  maintain  the 
nutrition  of  the  flaps,  to  preserve  these  vessels.  The  incision  is  therefore  made  close  to  the 
alveolar  borders  outside  the  vessels. — Ed.]  Other  branches  of  the  posterior  palatine  artery  pass 
through  the  accessory  palatine  canals.  The  posterior  and  accessory  palatine  canals  also  trans- 
mit the  descending  or  palatine  branches  (anterior,  middle,  and  posterior)  of  the  spheno-palatine 
ganglion. 

The  normal  tonsil  (see  Fig.  20  and  Plate  4)  projects  but  slightly,  if  at  all,  above  the  level  of 
the  surrounding  mucous  membrane,  and,  as  it  is  situated  in  the  niche  between  the  palatine 
arches,  it  is  visible  to  a  different  degree  in  different  subjects.  The  surface  of  the  tonsil  is  dotted 
by  the  apertures  of  numerous  crypts.  In  consequence  of  its  great  tendency  to  become  inflamed 
and  swollen,  its  relation  to  the  isthmus  of  the  fauces  is  particularly  important.  The  swelling  leads 
not  only  to  dysphagia,  the  tonsils  sometimes  meeting  in  the  median  line,  but  also  to  a  more  or  less 
marked  constitutional  depression.  It  is  clear  that  diseases  of  the  tonsils  may  extend  along  the 
upper  surface  of  the  soft  palate  to  the  choanae  (posterior  nares)  and  to  the  Eustachian  tubes,  and 
downward  into  the  pharynx  and  larynx.  The  operation  of  tonsillotomy,  so  frequently  performed 
upon  children,  is  often  followed  by  active  hemorrhage  which  may  be  difficult  to  arrest.  This  is 
due  to  the  tonsillar  branch  of  the  ascending  palatine  artery  (from  the  facial),  or,  if  the  incision  has 
penetrated  very  deeply,  to  the  trunk  of  the  ascending  palatine  itself.  Occasionally  a  particularly 
severe  hemorrhage  is  observed,  in  which  case  the  "slashing"  operator  may  not  only  have  removed 
the  tonsil  but  also  the  styloglossus  and  stylopharyngeus  muscles  and  lacerated  the  facial  artery, 
which  is  separated  from  the  tonsil  by  these  muscles.  The  internal  carotid  artery  is  quite  dis- 
tant and  is  not  endangered  in  tonsillotomy,  although  fatal  hemorrhage  has  been  observed  as 
the  result  of  a  tonsillar  abscess  ulcerating  into  this  vessel. 

The  pharynx  is  situated  behind  the  oral  cavity  and  passes  into  the  neck  without  any  sharp 
line  of  demarcation.  If  the  pharynx  is  incised  posteriorly,  it  will  be  seen  to  have  a  threefold 
communication.  The  upper  portion,  attached  to  the  base  of  the  skull,  opens  anteriorly  into 
the  nasal  fossas  through  the  choanae,  and  is  known  as  the  pars  nasalis  pharyngis  (naso-pfiarynx). 
Its  lower  boundary  is  formed  by  the  soft  palate,  which  is  in  apposition  with  the  dorsal  wall  of  the 
pharynx  during  deglutition,  and  so  divides  the  pars  nasalis  from  the  middle  portion  of  the  pharynx, 
the  pars  oralis.     The  orifice  of  the  Eustachian  tube  is  found  in  the  pars  nasalis  directly  behind  the 

^ posterior  extremity  of  the  inferior  turbinated  bone  (see  page  53  and  Fig.  19).  It  is  bounded 
posteriorly  by  the  torus  tubarius  (Eustachian  cushion),  the  prominence  due  to  the  trumpet- 
shaped  end  of  the  Eustachian  tube,  from  which  point  the  salpingopharyngeal  fold  (see  Fig.  19 
and  Plate  4)  may  be  seen  running  downward.  The  pocket-like  fossa  0}  Rosenmuller,  or  pharyn- 
geal recess,  is  situated  behind  the  torus  tubarius,  and  nearer  the  median  line  may  be  seen  the 
pharyngeal  tonsil,  which  varies  in  size  in  different  individuals  and  extends  into  the  fossa  of 


58  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

FlG.  21. — The  pharynx,  opened  longitudinally  from  behind,  with  the  three  anterior  communications:  with  the  nasal 

cavities,  with  the  mouth,  and  with  the  larynx. 

Rosenmuller.  It  lies  upon  the  firm  base  furnished  by  the  occipital  bone  at  the  base  of  the  skull, 
a  relation  which  is  favorable  for  the  extirpation  of  this  tonsil.  Diseases  of  the  pharyngeal  tonsil, 
particularly  the  proliferations  of  childhood,  may  involve  the  middle  ear  through  the  Eustachian 
tube  and  lead  to  suppuration  in  this  situation. 

The  pars  oralis  communicates  anteriorlv  with  the  mouth  through  the  isthmus  of  the  fauces. 
A  study  of  a  median  section  (Plate  4)  will  make  it  clear  to  the  reader  that,  although  unpleasant  to 
the  living  subject,  the  finger  may  be  introduced  into  the  mouth  and  passed  above  the  soft  palate , 
palpating  its  upper  surface,  the  vomer,  the  surroundings  of  the  choanae,  and  the  posterior  pharyn- 
geal wall  with  the  pharyngeal  tonsil.  It  will  also  be  understood  that  in  the  so-called  posterior 
rhinoscopy,  a  mirror  introduced  behind  the  soft  palate  will  show  the  choanae  and  the  turbinated 
bones  as  seen  from  behind. 

The  laryngeal  portion  of  the  pharynx  (pars  laryngea)  is  below  the  pars  oralis  and  leads 
anteriorly  into  the  larynx.  It  extends  to  the  level  of  the  sixth  cervical  vertebra,  where  the 
pharynx  ends  and  the  esophagus  commences..  The  aditus  ad  laryngem  (superior  aperture  of  the 
larynx)  is  bounded  above  by  the  edge  of  the  epiglottis  and  laterally  by  the  aryepiglottic  (aryteno- 
epiglottic)  folds,  in  which  the  more  or  less  prominent  cuneiform  and  corniculate  tubercles  (formed 
by  the  underlying  cartilages  of  the  same  name)  may  be  seen  with  the  laryngoscope.  Posteriorly 
in  the  median  line,  the  laryngeal  entrance  ends  at  the  interarytenoid  notch,  the  seat  of  predilection 
for  the  slit-like  erosions  of  chronic  laryngitis  and  for  tubercular  ulcers.  The  pharyngo-epiglottic 
folds  extend  from  the  pharynx  to  the  border  of  the  epiglottis.  The  pyrijorm  sinuses  are  situated 
internal  to  the  alae  of  the  thyroid  cartilage,  and  in  their  upper  portions  may  be  seen  a  fold  of 
mucous  membrane  (plica  nervi  laryngei)  produced  by  the  underlying  superior  laryngeal  nerve. 

A  loose  connective  tissue,  rich  in  lymphatic  vessels  and  containing  several  lymphatic  glands 
at  the  level  of  the  upper  cervical  vertebras,  connects  the  posterior  wall  of  the  pharynx  to  the 
prevertebral  fascia,  which  is  separated  from  the  spinal  column  by  only  the  thin  layer  of  the  pre- 
vertebral muscles  (longus  capitis  et  colli  muscles).  During  the  act  of  deglutition  the  pharynx 
moves  upon  this  loose  connective  tissue  (see  Fig.  26).  This  tissue  is  the  seat  of  retropharyngeal 
abscess,  which  may  produce  dysphagia  and  dyspnea  by  pressing  upon  the  pharynx,  the  choanae, 
the  soft  palate,  the  laryngeal  entrance,  and  the  trachea.  When  these  abscesses  are  favorably 
located,  they  may  be  opened  from  the  oral  cavity.  Since  this  loose  connective  tissue  accom- 
panies the  esophagus  into  the  thoracic  cavity,  it  forms  a  path  along  which  a  retropharyngeal 
abscess  may  extend  downward  into  the  mediastinum,  come  in  contact  with  the  pleura,  and  either 
break  into  the  pleural  cavity  (see  Plate  8,  b)  or  lead  to  pericarditis  by  extending  to  the  pericardium 
(see  Fig.  51).  The  relation  of  the  pharynx  to  the  cervical  vertebras  makes  it  possible  to  diagnos- 
ticate vertebral  fractures  and  dislocations  by  inspection  and  palpation  through  the  oral  cavity; 
for  example,  from  the  relation  of  the  anterior  arch  of  the  atlas  to  the  posterior  pharyngeal  wall  (see 
Plate  4)  it  is  clear  that  when  the  atlas  is  dislocated  anteriorly  it  may  be  recognized  as  a  hard 
prominence  in  the  posterior  pharyngeal  wall.  It  will  also  be  readily  understood  that  diseases  of 
the  cervical  vertebras  (such  as  caries)  may  lead  to  retropharyngeal  abscess  or  to  perforation  and 


Fig.    21. 


Clivus        Pharyngeal  tonsil 


Occipital 
condyle 


Superior  turbinated  bone 

Nasal  cavity 
Middle  turbinated  bone 

Inferior  turbinated  bone 


Velum  palatinum 

Uvula 
Oral  cavity 

Epiglottis 

Epiglottic  tubercle 

Cuneiform  tubercle 

(of  Wrisberg) 

Corniculate  tubercle 

(of  Santorini) 

Sinus  piriformis 


Esophagus 


Mastoid  process 


digastricus 
^Hypoglossal  nerve 

M.  stylohyoideus 

Torus  tubarius 

Septum  nasi 

Orifice  of  Eustachian   tube 


Palatopharyngeal  arch 
Palatoglossal  arch 
Faucial  tonsil 
Dorsum  linguae 

Lateral  glossoepiglottic  fold 

Aryepiglottic  fold 

Plica  nervi  laryngei 
Interarvtenoid  notch 


THE    ORGAN    OF   HEARING.  59 

the  extrusion  of  pieces  of  bone  into  the  pharynx.  The  median  sagittal  section  illustrated  in 
Plate  4  shows  that  tumors  proceeding  from  the  anterior  surface  of  the  cervical  vertebras,  from 
the  clivus,  or  from  the  body  of  the  sphenoid  meet  with  little  resistance  in  the  direction  of  the 
pharynx,  and  may  grow  through  the  choanae  into  the  nasal  fossas  and  then  extend  into  the  acces- 
sory nasal  cavities  or  through  the  cribriform  plate  into  the  cranial  cavity ;  they  may  also  push 
down  the  soft  palate  and  grow  toward  the  mouth. 


THE  ORGAN  OF  HEARING. 

The  cartilaginous  meatus  is  bounded  anteriorly  by  the  parotid  gland,  and  tumors  and  in- 
flammatory swellings  of  the  gland  may  consequently  lead  to  a  narrowing  of  the  auditory  canal. 
The  anterior  wall  of  the  bony  meatus  is  formed  by  the  thin  tympanic  plate  of  the  temporal  bone. 
This  tympanic  plate  is  the  partition  between  the  temporo-maxillary  articulation  and  the  external 
auditory  meatus  (see  Fig.  22),  through  which  affections  of  this  joint  may  extend  into  the  meatus. 
This  bony  plate  is  occasionally  fractured  and  displaced  into  the  meatus  when  the  condyle 
of  the  jaw  is  driven  backward  by  a  blow  upon  the  chin.  The  posterior  wall  of  the  bony  meatus 
varies  greatly  in  thickness;  it  is  often  nothing  more  than  a  thin  lamella  of  bone,  so  that  the 
cells  of  the  mastoid  process  are  in  close  proximity  (see  Fig.  22).  If  pus  is  present  in  these  cells 
and  an  early  external  opening  is  not  provided,  it  may  break  into  the  auditory  canal.  The  trans- 
verse diameter  of  the  middle  ear  or  cavum  tympani  is  very  small,  so  that  the  external  wall  (the 
drum-membrane)  is  only  about  two  millimeters  from  the  internal  wall  (the  promontory),  and  as  a 
result  of  inflammatory  processes  the  drum-membrane  may  become  adherent  to  the  promontory. 

The  thin  roof  of  the  tympanic  cavity  (the  legmen  tympani),  situated  in  the  middle  cranial 
fossa,  also  covers  a  portion  of  the  so-called  attic  or  epitympanic  recess,  a  large  space  which  connects 
the  tympanum  with  the  mastoid  cells.  This  is  the  important  path  by  which  suppurations  in  the 
middle  ear  so  often  extend  into  the  cells  of  the  mastoid  antrum.  The  outer  wall  of  the  mastoid 
process  must  then  be  opened,  since  it  is  rarely  so  thin  that  the  pus  may  perforate  externally 
spontaneously  and  gravitate  along  the  sternocleidomastoid  muscle.  The  thinness  of  the  tegmen 
tympani  (see  Fig.  23)  explains  the  possibility  of  the  destruction  of  the  bone  by  middle-ear  sup- 
purations and  the  escape  of  pus  beneath  the  dura  mater  or  the  extension  of  the  inflammation  to 
the  meninges  by  way  of  the  vascular  canaliculi.  If  the  suppuration  extends  to  the  brain,  an 
abscess  is  formed  in  the  temporal  lobe  which  rests  upon  the  tegmen  tympani  (see  page  35).  Fig. 
22  distinctly  shows  another,  though  practically  less  important,  relation  of  the  mastoid  process. 
It  will  be  observed  that  the  lateral  sinus  passes  in  the  immediate  vicinity  of  the  mastoid  process. 
This  explains  the  extension  of  suppurative  inflammations  of  the  middle  ear  to  the  lateral  sinus 
(sinus  thrombosis,  pyemia)  and  through  the  diseased  wall  of  the  sinus  to  the  cerebellum,  pro- 
ducing a  cerebellar  abscess.  These  important  conditions  may  be  best  understood  by  a  study  of 
the  base  of  the  skull. 

Fig.  23  also  shows  three  other  important  relations  of  surrounding  structures  to  the 
middle  ear: 

1.  In  the  region  colored  yellow,  the  facial  canal,  enclosing  the  facial  nerve,  projects  more  or 
less  into  the  tympanic  cavity.     In  this  situation  the  wall  of  the  canal  is  thin,  often  transparent, 


60  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

FlG.  22. — A  sagittal  section  through  the  mastoid  process,  the  external  auditory  meatus,  and  the  glenoid  fossa. 

Fig.  23. — The  temporal  bone  with  the  exposed  tympanum,  tympanic  antrum,  and  mastoid  cells.  The  relations 
of  the  facial  nerve,  internal  jugular  vein,  and  internal  carotid  artery  to  the  wall  of  the  tympanum  may  be  seen.  The 
different  areas  have  been  colored  yellow,  blue,  and  red  respectively. 

and  occasionally  even  perforated,  so  that  the  nerve  is  covered  only  by  the  tympanic  mucous 
membrane.  Inflammations  of  the  middle  ear  may  consequently  affect  this  nerve  and  produce 
a  facial  paralysis.  It  is  not  surprising  that  the  nerve  may  also  be  involved  in  caries  of  the  petrous 
portion  of  the  temporal  bone. 

2.  Caries  in  this  situation  has  led  to  fatal  hemorrhage  from  the  internal  carotid  artery.  The 
vessel  is  enclosed  in  the  carotid  canal  in  the  petrous  portion  of  the  temporal  bone  (see  page  34) 
and,  in  the  region  colored  red  in  the  illustration,  is  separated  from  the  tympanic  cavity  by  only  a 
thin  bony  lamella.  If  this  plate  is  broken,  as  in  a  fracture  of  the  base  of  the  skull,  the  blood 
poured  out  into  the  tympanic  cavity  may  break  through  the  membrana  tympani  and  escape  from 
the  ear  or  it  may  go  through  the  Eustachian  tube  and  appear  anteriorly  at  the  mouth  or  nose 
(see  Plate  4). 

3.  The  jugular  fossa,  situated  on  the  lower  surface  of  the  petrous  portion  of  the  temporal 
bone  and  accommodating  the  superior  bulb  or  sinus  of  the  internal  jugular  vein,  is  frequently 
so  deep  that  the  inner  and  lower  walls  of  the  middle  ear  are  correspondingly  thin  and  transparent 
or  even  perforated.  This  place  was  quite  thick  in  the  specimen  from  which  the  illustration  was 
made.    It  has  been  colored  blue. 

QUESTIONS. 

Why  is  it  that  contusions  of  the  face  are  not  followed  by  circumscribed  swellings,  as  is  the  case 
in  the  scalp  ? 

Where  may  the  pulsations  of  the  facial  artery  be  palpated  ? 

How  would  you  proceed  in  order  to  expose  the  infraorbital  and  the  inferior  dental  nerves  ? 

Which  large  accessory  nasal  cavity  is  endangered  in  neurectomy  of  the  infraorbital  nerve  ? 

How  may  the  place  of  exit  of  the  facial  nerve  be  exposed  at  the  base  of  the  skull  ? 

What  is  the  explanation  of  painful  mastication  and  dysphagia  in  diseases  of  the  parotid  gland  ? 

What  nerve  and  what  vessels  are  endangered  by  operations  upon  the  parotid  gland  ? 

Which  of  the  four  walls  of  the  orbit  is  the  strongest?  How  may  emphysema  of  the  orbit  and  ex- 
ophthalmos be  produced  by  fracture  of  any  of  the  other  three  walls  ?  What  cavities  are  situated  above, 
below,  and  to  the  inner  side  of  the  orbit,  and  what  is  the  direction  of  growth  of  tumors  originating  in 
these  cavities? 

How  may  the  lachrymal  gland  be  easily  exposed  ? 

What  is  the  relation  of  the  frontal  sinus  to  the  lachrymal  sac  ? 

Why  is  it  that  a  complete  retraction  of  the  orbital  muscles  need  not  be  feared  after  the  division 
of  their  tendinous  insertions  in  strabismus  operations  ? 

Through  what  thin  portions  of  the  base  of  the  skull  may  the  base  of  the  brain  be  most  easily  in- 
jured ? 

Through  what  portion  of  what  bone  may  tumors  of  the  base  of  the  skull  grow  into  the  nasal  fossas 
with  comparative  ease? 

What  is  the  explanation  of  the  relief  afforded  in  headache  by  a  pronounced  nasal  hemorrhage  ? 


Fia.   22. 


Mastoid  cell 


Mastoid 
foramen 


Tympanum 
Prominence  of  the  facial  canal 


Eminence  for  the  superior 
semicircular  canal 


Depression  for  the 
Gasserian  ganglion 

Carotid  canal 


Tympanic        Eminentia  articularis 
plate 

Glenoid  fossa 


External   auditory  meatus 


Mastoid  cells 


Epitympanic  recess 

Eminence  for  superior  semicircular  canal 
Prominence  of  facial  canal 
Promontory- 
Hiatus  canalis  facialis 

•   Carotid  canal 
i 


Fig.    2). 


Canal  for 
Eustachian  tube 


Mastoid  process 


Pars  tympanica 


THE    NECK.  6! 

What  are  the  four  ways  of  opening  the  maxillary  sinus  and  which  is  the  simplest  in  empyema  of 
this  cavity? 

What  situations  will  tumors  of  the  maxillary  sinus  reach  when  they  grow  inward,  upward,  forward, 
or  backward,  and  what  neighboring  organs  may  be  thereby  affected  ? 

Where  should  the  frontal  sinus  be  opened  and  what  is  the  location  of  its  opening  into  the  nasal  fossa  ? 

What  large  vessel  may  be  ruptured  and  produce  a  fatal  hemorrhage  from  the  nose  and  what  is 
the  route  taken  by  the  blood  in  such  a  case  ? 

What  mass  of  bone  and  what  accessory  cavities  of  the  nose  are  encroached  upon  when  tumors 
from  the  nasal  fossas  invade  the  orbit  ? 

How  may  the  pharyngeal  orifice  of  the  Eustachian  tube  be  reached  from  the  nostril  and  what 
should  be  noted  in  carrying  out  this  procedure  ? 

Where  is  the  orifice  of  the  parotid  duct  in  the  vestibulum  oris  and  where  is  there  a  normal  com- 
munication between  the  vestibule  and  the  oral  cavity,  which  may  be  utilized  for  feeding  under  certain 
circumstances  ? 

Where  may  the  submaxillary  duct  be  easily  opened  in  the  living  subject  ? 

In  what  situation  in  the  oral  cavity  may  hemorrhage  from  the  lingual  artery  be  controlled  by  suture  ? 

In  what  situation  in  the  oral  cavity  may  the  lingual  nerve  be  exposed  ?    The  inferior  dental  nerve  ? 

WTiat  arteries  may  give  rise  to  pronounced  hemorrhage  in  tonsillotomy  ? 

By  what  route  may  diseases  of  the  pharyngeal  tonsil  extend  into  the  middle  ear  ? 

Where  do  retropharyngeal  abscesses  arise  and  by  what  path  may  they  gravitate  into  the  chest 
and  produce  pleuritis  and  pericarditis  ? 

Where  may  diseases  of  the  cervical  vertebras  be  diagnosticated  from  the  mouth  ? 

How  do  tumors  and  swellings  of  the  parotid  gland  affect  the  external  auditory  meatus  ? 

What  relation  is  important  for  the  anterior,  and  what  one  for  the  posterior  wall  of  the  bonv  meatus  ? 

By  what  route  may  suppuration  in  the  middle  ear  lead  to  an  abscess  in  the  temporal  lobe,  and 
by  what  other  route  may  a  cerebellar  abscess  be  produced  ? 

In  middle-ear  disease,  what  nerve  may  give  rise  to  symptoms  of  paralysis  and  why? 

In  what  manner  may  a  sudden  fatal  hemorrhage  from  the  ear,  nose,  or  mouth  occur  in  the  course 
of  middle-ear  disease  ? 


THE  NECK. 


The  neck  may  be  regarded  as  a  passageway  for  important  organs  on  their  way  from  the 
head  to  the  trunk  and  from  the  trunk  to  the  head,  and  contains,  in  a  comparatively  small  space,  an 
unusually  large  number  of  structures  which  are  situated  in  the  anterior  and  lateral  cervical  regions. 
It  is  consequently  a  portion  of  the  body  which  claims  particular  attention  from  the  physician. 

The  neck  is  bounded  above  by  the  lower  margin  of  the  jaw,  by  the  mastoid  process,  and  by 
the  superior  curved  line  of  the  occiput.  Its  lower  boundary  is  formed  by  the  upper  margin  of 
the  sternum  (or  sternal  notch),  by  the  sternoclavicular  articulations,  by  the  clavicles,  by  the 
acromial  processes,  and  by  a  line  drawn  from  the  latter  to  the  spinous  process  of  the  vertebra 
prominens  (the  seventh  cervical).  These  boundaries  should  be  seen  and  felt  by  the  reader  in  his 
own  neck  and  in  the  necks  of  others.  The  student  should  also  observe  the  prominence  caused  by 
the  sternocleidomastoid  muscle  (particularly  when  the  head  is  turned  to  one  side),  the  anterior 


62  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

PLATE  5. 
A  cross-section  of  the  neck  at  the  level  of  the  thyroid  cartilage.     Frozen  section. 

border  of  the  trapezius  muscle,  the  more  or  less  deep  fossa  supraclavicularis  major  above  the 
clavicle,  the  jugular  fossa  above  the  upper  margin  of  the  sternum,  and  the  fossa  supraclavicularis 
minor,  which  is  distinctly  seen  above  the  sternoclavicular  articulation  only  when  there  is  a  marked 
interspace  between  the  two  heads  of  the  sternocleidomastoid  muscle.  The  latter  is  one  of  the 
rarer  situations  for  ligating  the  common  carotid  artery  (according  to  Zang)  and  the  area  for  aus- 
cultating venous  murmurs  in  the  internal  jugular  vein.  The  external  jugular  vein,  visible 
through  the  skin  when  well  filled,  may  be  distinctly  outlined  by  making  compression  upon  its 
terminal  portion  at  the  outer  side  of  the  sternocleidomastoid  muscle  [just  above  the  clavicle. 
— Ed.].  This  causes  the  vein  to  become  greatly  distended,  and  it  may  consequently  be  avoided  in 
operative  procedures  upon  the  neck. 

The  palpation  of  those  portions  of  the  respiratory  apparatus  which  are  situated  anteriorly 
is  of  particular  importance.  Starting  at  the  angle  of  the  thyroid  cartilage  (pomum  adami)  at  the 
incisura  thyroidea  superior,  the  hyoid  bone  may  be  palpated  posteriorly  as  far  as  the  greater 
cornua,  and  the  hyoid  bone  should  be  distinctly  differentiated  from  the  upper  border  of  the  thyroid 
cartilage  by  placing  the  thumb  and  index-finger  of  one  hand  upon  the  region  overlying  the  thyro- 
hyoid membrane.  Below  the  thyroid  notch  may  be  felt  the  blunt  anterior  edge  of  the  thyroid 
cartilage  leading  downward  to  the  ring  of  the  cricoid  cartilage,  which  is  connected  to  the  thyroid 
cartilage  by  means  of  the  rigid  and  distinct  middle  cricothyroid  ligament  (ligamentum  conicum). 
Below  the  cricoid  cartilage  is  the  first  tracheal  ring,  and  still  lower  down,  provided  that  it  is  well 
developed,  the  isthmus  oj  the  thyroid  gland  may  be  palpated.  The  pulsations  of  the  common 
carotid  artery  may  be  easily  felt  beside  the  larynx  at  the  inner  border  of  the  sternocleidomastoid 
muscle.  The  subclavian  artery  is  deeply  situated  in  the  larger  supraclavicular  fossa;  the  vessel 
runs  over  the  first  rib  and  its  pulsations  are  not  always  to  be  distinctly  palpated.  If  the  arm  is 
drawn  downward,  the  subclavian  artery  may  be  compressed  against  the  first  rib  for  the  purpose 
of  avoiding  or  controlling  hemorrhage  from  a  more  peripheral  region. 

As  is  shown  by  a  cross-section  (Plate  5),  the  soft  parts  of  the  neck  are  arranged  in  such  a 
manner  that  the  supporting  framework  of  the  cervical  vertebras  is  surrounded  by  muscles,  the 
great  mass  of  which  is  located  posterior  to  the  vertebral  column,  while  anteriorly  there  are  only 
the  weak  prevertebral  and  the  scalene  muscles.  This  osseous  and  muscular  mass  is  covered  by 
the  prevertebral  fascia  and  united  by  a  loose  connective  tissue  with  the  so-called  vascular  and 
visceral  columns,  which  are  almost  completely  covered  in  by  the  anterior  cervical  muscles  (the 
sternocleidomastoid  and  the  hyoid  muscles).  The  single  viscera  of  the  visceral  column,  com- 
posed of  the  cervical  portions  of  the  digestive  and  respiratory  tracts  (the  pharynx  and  esophagus, 
the  larynx  with  the  hyoid  bone  and  trachea),  are  situated  in  the  median  line  between  the  paired 
vascular  columns,  consisting  of  the  carotid  artery  and  the  internal  jugular  vein  together  with  the 
vagus  nerve.  This  grouping  of  the  soft  parts  forms  the  foundation  for  the  further  comprehension 
of  this  region.  The  visceral  column,  as  the  reader  may  readily  discover  in  his  own  neck,  is  easily 
moved  upon  the  anterior  surface  of  the  vertebral  column.  Tumors  situated  in  the  lateral 
portions  of  the  neck  consequently  easily  displace  the  larynx,  the  trachea,  and  the  esophagus 


Thyroid  cartilage 
Platysma 


u^sa-ub," 


M. 


Sternohyoid  m 
Sternothyroid  m. 


Laryngeal  cavity 
Pharyngeal  cavity 
Sternocleidomastoid  m. 

Superior  cornu  of 
thyroid  cartilage 

Inferior  constrictor  of 
pharynx 

Longus  colli  m. 

Longus  capitis  m. 
Scaleni  mm. 


Levator  scapuli  m. 
Semispinalis  cervicis  m. 

Semispinalis  capitis  m 
Splenitis 


Superior  thyroid  artery 


Trapezi 


carotis  com; 
Common  carotid  artery 


Sympathetic  nerve 
I'ocmnugastric  n. 


Internal  jugular  r. 
Lxtemal  jugular  r. 

Vertebral  a.  and  t. 


Body  of  vertebra 
Spinal  cord 


Vertebral  arch 


Spinous  proem 


62 


TOPOGRAPHIC   AND   APPLIED 


PLATE  5. 
A  cross-section  of  the 


'leidomastoid  mui 
tcXbecome  greatly  distended,  and  it     ' 


ojjfilimj  bimyriT 


bo  the  trajx 

clavicle,  the  jugular  :pper  m<;  le  sternum, 

minor,  which  is  distinct1.  ar  articulatior 

g  hv  Ixtween  the 

rarer  situations  y  (according  t< 

cultating  venous  ^  *>vs^^ 

through  the  sk*#»  vtuyn  w»»a/^ — "'  ^r*  ctly  outlinecNv 

terminal  por   - 

—Ed.).     T 

operatyi  "v    -?*Cnthe  neck 

The  pah  >^  ^-THions  of  the  respiratory  appavatua  vi 

rimK^m.  wnmo^  ^/^  >rtance.     Starting  at  the  angle  of  the  thyroid  car 

iAttfi>&fejJtkjt2 \_f         rprcion  the  hyoid  bone  may  be  palpated  po  .- 

•^^rWr^^HtOi^^  distinctly  differentiateT      ! 

v  vJiwt  ua^.ni _L. -r^trrcmrTa^^  of  one  hand jONOn 

HA'               |     ne.     Below  the  thyroid  notch  may  be  fete-fchcJiiunt 
.»  h« •*  iMncHto-MA, li^jj  d< > wn wa rd  to  the  ring  of  the  cricoid  cartilage,  whr 
^^nlajy^j  means  of  thengKraTntrtrStinrt  mjnVllr  cricothyroid  ; ~" 

BcluiA-iiiiptricoid  cartilage  is  the  first  tracheal  ring,  and 

developed,  the  isthmus  of  the  thyroi     gland  "may  be  ;  * — 

carotid  arterY  may  be  easily  felt  beside  the  larynx  at  ti 
'  rnii^  l£1l!,m7-V pfc — __ .  n  the« 


—  .m  biovHoms)2 

.Vli/fiJ   liiJSnVTErfl 

in  umco  lorwqug 
tea  hioT/rf) 

. to  lountenco  loiislul 

xXT/ii;rfq 

..m  illcn  «uanoJ 


s.forn  in 


-..m  id>q*3a  toMvsJ 


ulsations  . 

— 


run> 

drawn  d' 

of  avoiding  or 

Jj 
manner  that  the        N 
great  mass  of  which       ^ 
the  weak  prevertebral  an<       i? 
ia  and  u 
olumnSy  which  are  almo- 
id  and  the  ];; 

vascular  <. 
vagus  ner 
ef  this  region 
moved  upon 
portions  of 


| 

•  aikniqaimsg 


.m  *uin9kjr 


,m  zuissqtiT 


Tab., 


Cartilago  thyreoidea 

Platysma 

M.  sternohyoideus 

M.  sternothyreoideus 
Cavum  laryngift 
Cavum  pharyngis 

M.  sternoclcido 

mastoideus 
Cornu  superius 
cart,  thyreoideae 
M.  constrictor  - 
pharyngis  infer. 
M.  longus  colli  — 
M.  longus  capitis  - 
Mm.  scaleni  ss 


M.  levator  scapulae 

M.  semispinals 
cervicis 


Vt.  jugulares  anterior  es 


A.  thyreoidea  sup. 


M.  scmispinalis 
capitis 


A.  carotis  communis 

N.  sympathicus 

N. vagus 
V.  jugularis 
communis 

V.  jugularis  externa 
A.  et  V.  vertebralis 

.Corpus  vertebrae 

Medulla  spinalis 


ArcuS  vertebrae 


Processus  spiuosus 


THE   NECK.  63 

toward  the  opposite  side,  and  swellings  of  the  visceral  column  soon  lead  to  pressure  symptoms 
from  the  adjacent  vessels  and  nerves. 

The  skin  of  the  anterior  cervical  region  is  firmly  adherent  to  the  underlying  platysma  myoides 
muscle,  the  relation  being  similar  to  that  existing  between  the  skin  of  the  scalp  and  the  occipito- 
frontalis.  The  skin  consequently  follows  all  of  the  movements  of  the  platysma  and,  correspond- 
ing to  the  direction  of  the  muscular  fibers,  may  be  lifted  up  in  large  folds  running  particularly  in 
the  vertical  direction.  The  movability  of  the  skin  specially  adapts  it  to  the  performance  of 
plastic  operations. 

The  arrangement  of  the  muscles  in  the  anterior  and  lateral  portions  of  the  neck  renders 
possible  a  regional  subdivision  which  is  of  practical  value  in  the  living  subject.  The  inner 
margins  of  the  sternocleidomastoid  muscles,  which  converge  from  the  mastoid  processes  to  the 
upper  edge  of  the  sternum,  together  with  the  border  of  the  lower  jaw,  form  the  anterior  cervical 
region  (see  Fig.  24).  The  outer  margin  of  the  sternocleidomastoid,  the  anterior  margin  of  the 
trapezius,  and  the  upper  border  of  the  clavicle  bound  the  lateral  cervical  region.  The  anterior 
cervical  region  is  subdivided  into  a  small  suprahyoid,  and  into  a  larger  infrahyoid  region  by  the 
hyoid  bone  and  the  posterior  belly  of  the  digastric  muscle  (see  Fig.  24) ;  both  of  these  regions  may 
be  further  subdivided  into  a  single  median  region  and  into  a  lateral  paired  region.  The  sub- 
mental region  lies  above  the  hyoid  bone  and  is  bounded  upon  either  side  by  the  anterior  belly  of 
the  digastric  muscle ;  to  either  side  of  the  submental  region  is  found  the  submaxillary  region  or 
triangle  (containing  the  gland  of  the  same  name),  formed  by  the  lower  border  of  the  jaw  and  the 
two  bellies  of  the  digastric  muscle.  In  the  central  portion  of  the  infrahyoid  region  is  a  small 
diamond-shaped  space  between  the  hyoid  bone  and  the  upper  margin  of  the  sternum  and  bounded 
laterally  by  the  inner  margins  of  the  sternohyoid  'and  sternothyroid  muscles;  this  important  area 
is  known  as  the  median  cervical  region.  The  lateral  portion  of  the  infrahyoid  region  bears  im- 
portant relations  to  the  vessels  and  nerves  of  the  neck  and  is  called  the  carotid  triangle;  it  is 
bounded  by  the  posterior  belly  of  the  digastric,  by  the  anterior  margin  of  the  sternocleidomastoid, 
and  by  the  anterior  belly  of  the  omohyoid. 

The  Carotid  Triangle.— In  the  carotid  triangle  (see  Figs.  24  and  25)  the  pulsations  of  the 
common  carotid  artery  may  be  easily  felt  at  the  anterior  margin  of  the  sternocleidomastoid  muscle 
at  the  level  of  the  larynx.  The  carotid  artery  may  be  exposed  in  this  situation  by  an  incision 
made  parallel  to  the  anterior  margin  of  the  sternocleidomastoid  and  the  vessel  may  be  ligated 
through  this  incision  (the  point  of  election,  according  to  Cooper).  This  most  favorable  situation 
corresponds  to  the  level  of  the  anterior  tubercle  upon  the  transverse  process  of  the  sixth  cervical 
vertebra  (the  carotid  tubercle),  which  may  be  felt  when  the  anterior  margin  of  the  sternocleidomas- 
toid muscle  has  been  exposed;  it  also  corresponds  to  the  level  of  the  middle  cricothyroid  ligament. 
[The  anterior  belly  of  the  omohyoid  crosses  the  vessel  at  the  level  of  the  cricoid  cartilage.— Ed.] 
The  common  carotid  artery  ascends  from  the  lower  angle  of  the  triangle,  frequently  concealed 
beneath  the  margin  of  the  sternocleidomastoid  muscle,  and  divides  into  the  external  and  internal 
carotid  at  the  upper  margin  of  the  thyroid  cartilage  [opposite  the  lower  border  of  the  third  cervical 
vertebra.— Ed.].  The  internal  carotid  artery  is  normally  covered  in  the  first  part  of  its  course  by  the 
external  carotid.  [Strictly  speaking,  the  external  carotid  in  the  first  part  of  its  course  is  internal, 
that  is,  nearer  the  median  line,  and  anterior  to  the  internal  carotid.— Ed.]    To  the  outer  side  of 


64  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

Fig.  24. — The  anterior  cervical  region  (the  hypoglossal  nerve  has  been  displaced  slightly  downward). 

the  common  carotid  artery  is  situated  the  internal  jugular  vein,  which  when  well  filled  with  blood 
partly  overlies  the  carotid,  so  that  the  artery  is  more  deeply  placed  than  the  vein.  Behind  and 
between  these  two  vessels,  and  enclosed  within  their  common  connective-tissue  sheath,  the  vagus 
nerve  (see  Figs.  25  and  27  and  Plate  5)  runs  downward  to  the  upper  opening  of  the  thorax.  When 
the  great  vessels  of  the  neck  are  injured,  this  nerve  is  also  easily  involved;  it  should  be  carefully 
avoided  in  ligation  of  the  carotid.  The  good  operator  should  also  spare  the  descendens  hypoglossi 
nerve  (see  Figs.  24  and  25),  which  runs  downward  upon  the  carotid  sheath,  although  its  division  is 
not  followed  by  important  symptoms.  This  small  nerve,  together  with  branches  from  the  second 
and  third  cervical  nerves,  forms  the  ansa  hypoglossi,  from  which  the  infrahyoid  muscles  receive 
their  motor  branches.  One  or  two  superior  thyroid  veins  may  run  almost  transversely  across  the 
carotid  (see  Fig.  27)  and  also  aid  in  rendering  the  ligation  of  the  vessel  more  difficult.  At  the 
margin  of  the  omohyoid  muscle  may  be  seen  the  thyroid  gland,  which  projects  into  the  carotid 
triangle  to  a  varying  extent,  dependent  upon  the  degree  of  its  development.  The  superior  thyroid 
artery,  the  first  branch  of  the  external  carotid,  runs  downward  to  this  gland  in  an  arched  and 
tortuous  direction.  It  gives  off  the  small  superior  laryngeal  artery,  which,  together  with  the 
sensory  superior  laryngeal  nerve  from  the  pneumogastric,  enters  the  larynx  through  the  thyro- 
hyoid membrane  below  the  greater  cornu  of  the  hyoid  bone.  The  lingual  artery  is  given  off 
from  the  external  carotid  above  the  superior  thyroid;  it  runs  anteriorly  and  soon  disappears 
beneath  the  hyoglossus  muscle  to  supply  the  tongue.  It  must  sometimes  be  li gated  to  control 
hemorrhage  after  injuries  to  the  tongue  or  for  the  purpose  of  preventing  hemorrhage  during  opera- 
tions for  lingual  carcinoma.  The  vessel  may  be  easily  exposed  by  an  incision  just  above  the 
greater  cornu  of  the  hyoid  bone;  after  dividing  the  skin,  the  platysma,  the  deep  fascia,  and  the 
hyoglossus  muscle,  the  artery  will  be  found  in  the  angle  between  the  posterior  belly  of  the  digastric 
muscle  and  the  greater  cornu  of  the  hyoid  bone.  The  artery  may  also  be  ligated  further  anteriorly 
in  the  submaxillary  triangle.  Just  above  the  lingual  artery  (and  often  arising  with  it  from  a 
common  trunk)  is  given  off  the  third  of  the  three  anterior  branches  of  the  external  carotid — the 
facial  artery.  This  is  the  largest  vessel  in  the  submaxillary  triangle  (see  page  65),  and  it  enters 
this  region  by  passing  beneath  the  posterior  belly  of  the  digastric  and  the  stylohyoid  muscles. 
The  other  branches  of  the  external  carotid  in  the  carotid  triangle  are  the  ascending  pharyngeal 
artery,  passing  upward  and  inward  to  the  base  of  the  skull,  and  the  occipital  artery,  which  runs 
upward  and  backward  (see  Plate  2).  The  carotid  artery  is  accompanied  by  a  chain  of  deep 
cervical  lymphatic  glands  which  frequently  become  diseased.  Abscesses  originating  within  these 
glands  may  point  along  the  vessels  until  they  reach  the  connective  tissue  of  the  mediastinum,  from 
which  situation  the  pus  may  extend  in  various  directions. 

The  hypoglossal  nerve,  the  motor  nerve  of  the  tongue,  is  found  in  the  upper  portion  of  the 
carotid  triangle ;  it  passes  forward  in  a  curved  direction,  the  convexity  being  downward,  crosses 
the  external  carotid  and  then  the  facial  artery,  and  enters  the  submaxillary  region  in  company  with 
the  lingual  vein  by  passing  underneath  the  posterior  belly  of  the  digastric  muscle.  The  esophagus 
and  the  lower  portion  of  the  pharynx  may  be  reached  through  the  carotid  triangle  by  an  incision 
made  along  the  inner  margin  of  the  sternocleidomastoid  muscle  (see  page  67). 


Fig.   24 


Submental    lymphatic 
glands 
Submaxillary  lym- 
phatic glands 

Facial  vein 
Submaxillary  gb.nd 

Parotid  gland 

Anterior  division  of 

temporomaxill.  vein 

M.  stylohyoideus 

Lingual  artery 

Hypoglossal  nerve 

Internal  carotid  artery 

Internal    jugular  vein 

External  carotid   artery 

Facial  vein 
Superior  thyroid  art. 

Descendenshypoglossi 

Common  carotid  art. 

Thyroid  gland 


Isthmus  of  thyroid 
gland 


Tr.\chea 


Middle  thyroid  vein 


M.  platysma  myoides 


M.  digastricus 
(anterior  belly) 

M.  mylohyoideus 
M.  masseter 

Hyoid  bone 

M.  digastr.  (post,  belly) 
Middle  thyro-hyoid.  lig. 
M.  hyoglossus 
Sup.  laryngeal  nerve 
Thyroid  cartilage 
Sup.  laryngeal  artery 
M.  omohyoideus 
Jl.  sternohyoideui 

Crico-thyroid  ligament 
Internal  jugular  vein 
M.   slernocleido- 

mastoideus 
M.   cricotbyreoideus 
Cricoid  cartilage 
Trachea 


M.   trapezius 

Sternal  port,  of  m  sterno- 
cleidomastoideus 

M.  omohyoideus 

Clavicular  portion  of 
sternocleidomastoideus 
Clavicle 
M.  sternothyreoideus 


THE  NECK.  65 

The  Submaxillary  Triangle.— The  submaxillary  triangle,  which  is  reached  by  following  the 
course  of  the  hypoglossal  nerve  and  the  facial  artery,  is  bounded  by  the  lower  margin  of  the  jaw 
and  by  the  two  bellies  of  the  digastric  muscle.  After  the  removal  of  the  skin,  platysma,  and  deep 
fascia  we  find  that  the  largest  structure  in  this  region  is  the  submaxillary  gland  (see  Figs.  24  and 
25),  which  may  even  be  visible  through  the  skin  in  markedly  emaciated  individuals.  The  fascia 
covering  the  gland  is  rather  firm  and  offers  a  certain  resistance  to  the  spontaneous  external  rupture 
of  glandular  abscesses.  The  submaxillary  lymphatic  glands  are  situated  along  the  lower  margin 
of  the  jaw  and  the  upper  margin  of  the  submaxillary  salivary  gland,  some  of  them  being  partly 
imbedded  in  the  latter  structure.  Since  these  glands,  like  those  situated  nearer  the  median  line 
(the  submental  lymphatic  glands),  receive  the  lymphatics  from  the  face,  they  may  easily  be 
affected  in  diseases  of  the  face  (such  as  labial  carcinoma)  and  require  extirpation.  The  sub- 
maxillary gland  receives  numerous  branches  from  the  facial  artery,  which  runs  from  behind  for- 
ward in  this  triangle.  This  vessel  is  imbedded  in  the  substance  of  the  submaxillary  gland  and 
leaves  the  cervical  region  at  the  anterior  border  of  the  masseter  muscle,  where  it  lies  directly  upon 
the  margin  of  the  jaw.  The  chief  branch  of  the  facial  artery  in  this  region  is  the  submental,  which 
is  covered  by  the  gland  and  runs  toward  the  chin  upon  the  mylohyoid  muscle ;  it  is  accompanied 
by  the  small  mylohyoid  branch  of  the  inferior  maxillary  nerve  (motor).  At  the  angle  of  the  jaw 
the  facial  vein  is  joined  by  the  anterior  division  of  the  temporo-maxillary  vein  (see  Fig.  24).  [This 
union,  according  to  Cunningham,  usually  takes  place  a  little  below  the  angle  of  the  jaw. — Ed.] 
If  the  submaxillary  gland  is  lifted  up,  the  submaxillary  duct  may  be  seen  anteriorly  in  the  depths 
of  the  triangle  as  it  disappears  beneath  the  mylohyoid  muscle ;  still  deeper  and  at  a  higher  level 
the  lingual  nerve  is  in  relation  with  the  submaxillary  gland  and  the  small  submaxillary  ganglion. 
The  comparatively  small  glossopharyngeal  nerve  is  found  near  the  pharynx,  deeply  situated 
between  the  styloglossus  and  stylopharyngeus  muscles;  it  passes  beneath  the  tonsil  to  end  in  the 
circumvallate  papillas  of  the  lingual  mucous  membrane. 

The  median  cervical  region  is  situated  beneath  the  hyoid  bone  and  extends  to  the  upper 
margin  of  the  sternum.  It  is  bounded  above  and  to  the  outer  side  by  the  inner  margins  of  the  sterno- 
hyoid muscles,  and  below  and  to  the  outer  side  by  the  sternothyroid  muscles,  presenting  a  narrow 
triangular  surface  in  this  situation  (see  Fig.  24).  The  greatest  breadth  of  this  narrow  region  is 
about  two  centimeters  and  it  is  situated  approximately  midway  between  the  hyoid  bone  and  the 
sternum.  In  this  important  region  the  trachea  is  covered  only  by  skin  and  fascia.  Incised 
wounds  of  the  trachea  are  consequently  common  in  this  region,  particularly  in  cases  of  suicide,  and 
the  physician,  under  certain  circumstances,  must  rapidly  perform  tracheotomy  in  this  situation  in 
order  to  save  the  life  of  his  patient.  The  structures  which  may  be  palpated  through  the  skin  at 
this  place  (see  page  62)  are  responsible  for  the  subdivision  into  the  Mowing  regions:  the  hyoid 
region  (hyoid  bone),  the  subhyoid  region  (the  thyrohyoid  membrane  or  ligament),  the  laryngeal 
region  (the  larynx),  the  thyroid  region  (the  thyroid  gland),  and  the  suprasternal  region  (just  above 
the  sternum). 

In  the  subhyoid  region  the  respiratory  tract  cannot  be  entered  by  simply  dividing  the  middle 

thyrohyoid  ligament  (see  Figs.  24  and  26).     Behind  the  ligament  there  is  a  relatively  thick  mass  of 

fat,  which  extends  for  about  one  centimeter  in  the  sagittal  plane  and  is  limited  posteriorly  by  the 

hyoepiglottic  ligament,  passing  from  the  epiglottis  to  the  hyoid  bone,  and  by  the  attached  end  of 

5 


66  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

Fig.  25. — The  submaxillary  and  carotid  triangles. 


the  epiglottis.  This  mass  of  fat  produces  the  so-called  epiglottic  tubercle,  which  projects  into  the 
vestibule  of  the  larynx.  It  will  be  seen  that  this  fatty  tissue  is  not  particularly  adapted  for  opera- 
tive procedures.  As  a  result  of  laryngitis,  abscesses  occasionally  form  in  this  mass  of  fat,  which 
may  be  evacuated  externally  by  an  incision  through  the  thyrohyoid  ligament.  The  subhyoid 
region  is  broadest  at  its  lower  boundary,  which  is  formed  by  the  thyroid  notch.  In  the  median 
line  there  is  an  inconstant  bursa  situated  between  the  thyrohyoid  membrane  and  the  sternohyoid 
muscle;  it  extends  upward  beneath  the  hyoid  bone  and  occasionally  leads  to  the  development  of 
hygromata.    There  is  also  a  bursa  lower  down  over  the  angle  of  the  thyroid  cartilage. 

The  largest  portion  of  the  laryngeal  region  is  taken  up  anteriorly  by  the  thyroid  cartilage, 
which  causes  the  hard  projection  (in  the  male)  known  as  the  Adam's  apple.  The  thyroid  cartilage' 
is  connected  to  the  cricoid  cartilage  by  the  tense  crico-thyroid  ligament  (or  ligamentum  conicum). 
This  is  the  situation  in  which  the  larynx  may  be  most  easily  opened  below  the  vocal  cords.  The 
incision  may  be  carried  upward,  dividing  the  thyroid  cartilage  (thyrotomy),  or  downward,  divid- 
ing the  cricoid  cartilage  (cricotomy).  The  small  cricothyroid  artery,  lying  upon  the  cricothyroid 
ligament,  possesses  no  special  surgical  importance.  A  median  sagittal  section  (see  Fig.  26)  shows 
that  abscesses  resulting  from  perichondritic  processes  affecting  the  arytenoid  cartilages  and  the 
lamina  of  the  cricoid  cartilage,  which  form  the  posterior  wall  of  the  larynx,  may  rupture  anteriorly 
into  the  larynx,  (producing  respiratory  disturbances)  or  posteriorly  into  the  laryngeal  portion  of 
the  pharynx  (causing  dysphagia).  Perichondritis  of  the  anterior  wall  of  the  larynx  (the  thyroid 
cartilage  and  the  ring  of  the  cricoid  cartilage)  may  lead  to  the  formation  of  abscesses  which  either 
point  anteriorly  beneath  the  skin  or  rupture  into  the  laryngeal  cavity. 

The  narrow  thyroid  region  is  situated  just  below  the  laryngeal  region  and  corresponds  to 
the  isthmus  of  the  thyroid  gland,  which  is  in  relation  with  the  upper  tracheal  rings  and  frequently 
touches  the  cricoid  cartilage.  In  children  the  isthmus  of  the  thyroid  gland  usually  extends  to  a 
higher  level  than  in  adults,  but  it  does  not  reach  beyond  the  cricoid  cartilage ;  it  is  also  more 
firmly  fixed  to  the  trachea  in  the  child  than  in  the  adult.  When  high  tracheotomy  is  performed, 
the  isthmus  must  be  separated  from  the  trachea  by  blunt  dissection  and  pushed  downward,  so 
that  the  incision  for  the  introduction  of  the  tracheal  tube  will  not  injure  the  thyroid  gland.  The 
performance  of  this  operation  is  not  infrequently  complicated  by  the  presence  of  a  middle  lobe  of 
the  thyroid  gland,  which  often  extends  up  to  the  hyoid  bone.  It  is  situated  either  exactly  in  the 
median  line  or  somewhat  to  one  side.  The  thyroid  gland,  covered  by  the  sternothyroid  and 
sternohyoid  muscles,  extends  laterally  into  the  carotid  triangle  and  comes  in  contact  with  the 
lowest  portion  of  the  pharynx  and  the  commencement  of  the  esophagus.  From  the  position  of  the 
thyroid  gland  it  is  clear  that  thyroid  swellings  and  tumors  must  lead,  first  of  all,  to  pressure- 
symptoms  from  the  trachea  with  changes  in  the  tracheal  cartilage,  and  then  to  involvement  of  the 
large  vessels  and  nerves  of  the  neck.  The  inferior  laryngeal  nerve  runs  upward  behind  the  thyroid 
gland  between  the  trachea  and  the  esophagus  and  should  be  carefully  avoided  in  the  extirpation  of 
goiters,  as  injuries  of  this  nerve  are  followed  by  paralyses  of  the  laryngeal  muscles  of  the  same  side. 
The  trachea  is  situated  considerably  more  deeply  below  than  above  the  thyroid  gland.  This  fact 
in  itself  complicates  the  performance  of  tracheotomy  in  this  situation  (low  tracheotomy),  and 


Fig.  25. 


Mandible 


Submaxillary  gland 

Mylohyoid  nerve 

M.  masseter 


Submental  artery 
M.  mylohyoideus 


Lingual 
nerve 


Parotid  gland 


M.  digastricus 
'anterior  belly) 

M.  hyoglossus 
Lingual  artery 

Thyrohyoid  nerve -^A 

Hyoid  bone 

Superior  laryngeal  nerve 
Superior  laryngeal  artery 

Superior  thyroid  artery    ' 

Larynx £_   ■ 

M.  sternohyoideus 

Thyroid  gland W-fcli 

M.   oni oh yoi dei is _____ Jj 


M.  sternothyreoideus 


M.  pterygoideus  interims 
-Occipital  artery 

M    styloglossus 

M.   Mylohyoideus 

M.  digastricus  (posterior  belly^ 

Ascending  palatine  artery 

Spinal  accessory  nerve 

Hypoglossal  nerve 

Facial  artery 

Internal  carotid  artery 
Vagus  nerve 

Ascending  pharyngeal  artery 
External  carotid   artery 

Descendens  hypoglossi 


Common  carotid  artery 
Pharyn* 

Vertebral  column 
M.  sternocleidomast 


Sympathetic  nerve 


THE   NECK.  5- 

additional  reasons  for  the  comparative  infrequency  of  this  operation  are  furnished  by  the  numer- 
ous intercommunicating  veins  which  pass  downward  from  the  thyroid  gland,  as  the  thyroid 
plexus,  to  empty  into  the  middle  thyroid  vein,  a  tributary  of  the  left  innominate  vein  (see  Fig.  24). 
The  inferior  thyroid  veins  take  origin  in  numerous  radicles  from  the  isthmus  and  lateral  lobes 
of  the  thyroid.  Passing  downward,  the  left  empties  into  the  left  innominate  vein,  the  right  into 
the  junction  of  right  and  left  innominate  veins.  Frequent  anastomoses  between  the  veins  of  the 
two  sides  may  result  in  a  rather  intricate  plexus  in  front  of  the  lower  cervical  portion  of  the 
trachea.  Sometimes  this  anastomosis  results  in  the  formation  of  a  single  inferior  thyroid  vein, 
which  usually  empties  into  the  left  innominate  vein,  but  may  empty  into  the  right.— Ed.]  The 
line  of  incision  is  also  occasionally  crossed  by  an  anomalous  thyroid ea  ima  artery  from  the  arch  of 
the  aorta. 

The  trachea  begins  at  the  lower  border  of  the  larynx,  where  the  pharynx  ends  and  the  esoph- 
agus commences.  This  is  at  about  the  level  of  the  sixth  cervical  vertebra.  The  trachea  bifurcates 
into  the  two  bronchi  within  the  thorax  (see  page  114)  opposite  the  fourth  dorsal  vertebra  [or  the 
upper  border  of  the  fifth. — Ed.];  a  cervical  portion  and  a  thoracic  portion  of  the  trachea  may  there- 
fore be  differentiated,  the  dividing-line  being  situated  at  the  first  dorsal  vertebra.  The  cervical 
portion  of  the  trachea  may  be  further  subdivided  into  three  parts— that  beneath  the  thyroid  gland, 
a  short  portion  above  the  gland,  and  a  longer  portion  below  it.  As  the  trachea  passes  backward 
as  well  as  downward,  it  constantly  becomes  further  removed  from  the  skin  of  the  neck,  through 
which  it  may  be  reached  with  comparative  ease  above  the  thyroid  isthmus.  Below  the  isthmus 
the  trachea  is  covered  by  the  veins  of  the  thyroid  plexus  and  by  a  varying  amount  of  fat  in  the 
jugular  fossa.  When  the  head  is  held  erect,  the  trachea  consequently  does  not  pursue  a  vertical 
course,  but  one  that  is  directed  from  above  downward  and  slightly  backward.  In  children 
the  trachea  is  covered  above  the-  sternum  by  the  thymus  gland,  which  projects  above  the  upper 
opening  of  the  thorax  to  a  greater  or  less  extent. 

The  esophagus  is  situated  posterior  to  the  trachea  and  commences  opposite  the  cricoid 
cartilage  about  15  centimeters  from  the  incisor  teeth  [about  six  inches. — Ed.].  It  deviates  some- 
what to  the  left  of  the  median  line,  projecting  slightly  beyond  the  left  side  of  the  trachea; 
esophagotomy  for  the  removal  of  foreign  bodies  is  consequently  best  performed  by  making  the 
incision  along  the  inner  border  of  the  left  sternocleidomastoid  muscle.  The  skin,  platysma,  and 
fascia  are  divided,  the  edge  of  the  sternocleidomastoid  is  drawn  to  the  outer,  and  the  larynx, 
trachea,  and  thyroid  gland  to  the  inner  side.  The  inferior  thyroid  artery  must  sometimes  be 
ligated;  particular  care  should  be  taken  to  avoid  the  inferior  laryngeal  nerve,  which  runs  in  the 
groove  between  the  trachea  and  the  esophagus.  The  same  incision  will  serve  for  the  evacuation  of 
those  retropharyngeal  abscesses  which  cannot  be  reached  through  the  mouth,  and  also  for  the 
ligation  of  the  inferior  thyroid  artery.  The  esophagus,  like  the  pharynx,  is  fixed  to  the  vertebral 
column  by  loose  connective  tissue  (see  Fig.  26)  which  offers  no  great  resistance  to  the  down- 
ward extension  of  retropharyngeal  abscesses.  Swellings  and  tumors  of  the  lymphatic  glands 
situated  alongside  of  the  esophagus  may  lead  to  esophageal  stenosis;  suppurations  in  these 
glands  or  in  the  thyroid  gland  may  rupture  into  the  esophagus.  The  narrowing  of  the 
esophageal  lumen  at  the  level  of  the  cricoid  cartilage  is  described  upon  page  115.  The 
esophagus  is  only  loosely  attached  to  the  trachea  by  connective  tissue.     Running  upward  to  the 


68  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

Fig.  26. — A  median  sagittal  section  of  the  neck  (formalin  preparation). 

larynx  between  the  trachea  and  the  esophagus  are  the  two  motor  laryngeal  nerves,  the  inferior 
or  recurrent  laryngeal  nerves  (see  page  67). 

In  the  middle  line  of  the  neck  there  is  occasionally  a  superficial  median  vein.  As  a  rule, 
however,  the  more  or  less  prominent  anterior  jugular  veins  lie  to  either  side  of  the  median  line  in 
the  anterior  cervical  region.  They  commence  in  the  mental  region,  run  downward  upon  the 
infrahyoid  muscles,  and  pass  beneath  the  origin  of  the  sternocleido  muscles  to  empty,  together 
with  the  external  jugular  veins,  into  the  subclavian  vein.  In  the  median  line  above  the  sternum 
the  two  veins  are  united  by  a  transverse  vein  (the  arcus  venosus  juguli)  which  is  endangered  in  the 
operation  of  low  tracheotomy.  The  left  innominate  vein  (see  page  112)  only  exceptionally  projects 
above  the  upper  margin  of  the  sternum,  and  consequently  is  not  usually  endangered  in  operative 
procedures.  The  external  jugular  vein  runs  downward  upon  the  sternocleidomastoid  muscle  in 
the  lateral  cervical  region,  and  during  life  is  often  visible  through  the  skin  (see  page  62).  Below 
the  ear  it  anastomoses  with  the  posterior  division  of  the  temporo-maxillary  vein;  it  collects  the 
blood  from  the  occipital  and  posterior  auricular  veins  and  empties  into  the  subclavian  vein  above 
the  clavicle  to  the  outer  side  of  the  attachment  of  the  sternocleidomastoid  muscle  (where  it  may 
be  compressed — see  page  62).  If  the  tendon  of  the  sternocleidomastoid  is  divided  above  the 
clavicle  for  torticollis,  care  should  be  taken  to  avoid  injuring  the  external  jugular  vein.  The 
origin  of  this  muscle  from  the  sternum  and  from  the  clavicle  also  conceals  the  more  deeply  situated 
vessels  of  this  region.  The  common  carotid  artery  may  be  ligated  between  the  two  heads  of  the 
muscle,  but  on  account  of  its  depth  in  this  situation  the  vessel  is  reached  with  much  greater  dif- 
ficulty than  at  the  level  of  the  cricoid  cartilage  (see  page  62).  There  is  little  danger  of  wounding 
the  common  carotid  artery  in  the  operation  for  torticollis.  If  we  penetrate  between  the  two  heads 
of  the  sternocleidomastoid  muscle,  we  come  upon  the  internal  jugular  vein;  this  must  be  pushed 
outward,  and  the  sternohyoid  and  sternothyroid  muscles  inward,  to  expose  the  common  carotid 
artery  (see  Fig.  27).     The  vagus  nerve  must  be  carefully  avoided  (see  page  64). 

In  the  lateral  cervical  region  the  majority  of  the  nerves  originating  in  the  cervical  plexus 
are  visible  at  the  posterior  margin  of  the  sternocleidomastoid  muscle,  while  the  plexus  itself, 
formed  by  the  anterior  divisions  of  the  four  upper  cervical  nerves,  is  concealed  by  this  muscle. 
The  following  cutaneous  nerves  may  be  seen: 

1.  The  occipitalis  minor  nerve,  which  runs  close  to  the  insertion  of  the  sternocleidomastoid 
muscle  to  the  lateral  portion  of  the  occipital  region.  It  may  be  superficially  or  deeply  placed,  is 
often  double,  and  frequently  inosculates  with  the  occipitalis  major  nerve  (see  page  28). 

2.  The  auricular  is  magnus  nerve,  larger  than  the  preceding  and  appearing  below  it  at  the 
margin  of  the  sternocleidomastoid  muscle.  It  runs  directly  upward  to  the  ear  upon  the  sterno- 
cleidomastoid muscle,  supplies  the  skin  of  the  auricle,  that  of  the  anterior  and  posterior  auricular 
regions,  and  also  the  cutaneous  lining  of  the  external  auditory  meatus.  It  frequently  divides  into 
an  anterior  and  a  posterior  branch. 

3.  The  superficialis  colli  nerve  (dividing  into  a  superior  and  an  inferior  branch)  runs  anteriorly 
at  right  angles  to  the  sternocleidomastoid  muscle  and  pierces  the  platysma  in  order  to  reach  the 
skin.  It  is  divided,  usually  at  the  anterior  margin  of  this  muscle,  in  exposing  the  great  vessels 
of  the  neck.     Its  upper  branches  inosculate  with  the  cervical  branches  of  the  facial  nerve. 


Fig.  26. 


Axis 


Third   cervical  nerve 
Palatopharyn- 
geal arch 

Oral  portion  of 
the  pharynx 


Laryngeal  port, 
of  the  pharynx 


Retro-pharyn 
geal  connec- 
tive tissue 


Seventh  cervical 
vertebra 

Eighth  cervical  nerve 
Esophagus 


First  thoracic 
nerve 


Uvula 


Faucial  tonsil 

Palatoglossal  arch 

M.  genioglossus 


M.  genio- 
hyoideus 
M.  mylo- 
hyoideus 


Ilyoid  bone 
Epiglottic  cartilage 

•Middle  thyrohyoid  ligament 


M.  arytenoideus 
Ventricle  of  larynx 
Thyroid  cartilage 

Lamina  of  cricoid  cartilage 


Anterior  portion  of  cricoid  cartilage 
First  tracheal  ring 
-Thyroid  gland. 


THE  NECK. 


69 


4.  A  considerable  number  of  supraclavicular  nerves  run  downward  in  the  region  of  the 
supraclavicular  fossa,  some  of  them  passing  downward  anteriorly  and  posteriorly  over  the  sternum 
and  the  acromion;  they  supply  the  skin  of  the  superior  thoracic  region  and  of  the  shoulder. 

The  spinal  accessory  nerve,  after  perforating  and  supplying  the  sternocleidomastoid,  leaves 
the  posterior  margin  of  this  muscle  and  runs  obliquely  downward  and  outward  in  the  space  be- 
tween the  splenius  and  the  levator  anguli  scapulae  to  the  trapezius  muscle.  [The  spinal  accessory 
nerve  enters  the  deep  surface  of  the  sternocleidomastoid  about  one  and  a  half  inches  or  less 
below  the  tip  of  the  mastoid  process;  perforating  the  muscle,  it  emerges  at  or  a  little  below  the 
middle  of  the  posterior  border.  A  line  from  midway  between  the  angle  of  the  jaw  and  the  tip  of 
the  mastoid  through  the  middle  of  the  posterior  border  of  the  sternocleidomastoid  continued  across 
the  posterior  triangle  to  the  anterior  edge  of  the  trapezius  at  the  level  of  the  seventh  cervical  spine 
sufficiently  indicates  its  course. — Ed.]  This  muscle  is  also  directly  supplied  by  branches  of  the 
cervical  plexus  which  may  be  found  lower  down  in  the  posterior  triangle.  In  the  neighborhood 
of  the  supraclavicular  fossa  the  posterior  belly  of  the  omohyoid  muscle  appears  beneath  the  pos- 
terior margin  of  the  sternocleidomastoid  and  runs  downward  and  outward  to  disappear  beneath 
the  clavicle.  Together  with  the  clavicle  and  the  posterior  margin  of  the  sternocleidomastoid,  it 
bounds  the  small  subclavian  triangle  (trigonum  omoclaviculare).  In  lean  individuals  the  omo- 
hyoid muscle  may  often  be  seen  when  the  hyoid  bone  and  larynx  are  elevated  during  the  act  of 
deglutition. 

In  the  depths  of  the  lateral  cervical  region  (see  Fig.  27)  above  the  clavicle,  and  forming,  so 
to  speak,  the  floor  of  this  triangle,  may  be  seen  the  scalene  muscles.  The  anterior  scalene  muscle 
passes  from  the  transverse  processes  of  the  third,  fourth,  fifth,  and  sixth  cervical  vertebras  to  the 
scalene  tubercle  of  the  first  rib;  the  middle  scalene  muscle  runs  from  the  transverse  processes  of 
all  of  the  cervical  vertebras  to  the  outer  surface  of  the  first  rib.  These  two  muscles  form  the 
typical  scalene  slit  or  scalene  triangle,  the  apex  of  which  is  directed  upward  and  the  base  down- 
ward. Behind  these  muscles  is  the  posterior  scalene  muscle,  which  extends  from  the  transverse 
processes  of  the  fifth,  sixth,  and  seventh  cervical  vertebras  to  the  outer  surface  of  the  second  rib. 
Above  the  scalene  muscles  is  the  levator  anguli  scapula,  arising  from  the  transverse  processes  of 
the  four  upper  cervical  vertebras  and  inserting  into  the  superior  angle  of  the  scapula,  and  the 
splenius  capitis  et  cervicis,  which  arises  from  the  ligamentum  nuchse  and  the  spinous  processes 
of  the  first  to  the  sixth  dorsal  vertebras  and  is  inserted  into  the  mastoid  process  and  the  transverse 
processes  of  the  first  two  or  three  upper  cervical  vertebras. 

The  supraclavicular  lymphatic  glands  are  grouped  above  the  clavicle;  they  receive  the  lymph 
from  the  back  of  the  neck  as  high  up  as  the  ear  and  are  frequently  diseased,  particularly  in  tuber- 
culosis. 

If  the  sternocleidomastoid  muscle  is  removed,  the  previously  concealed  continuation  of  the 
vascular  and  nervous  trunk  is  exposed  as  it  passes  downward  toward  the  clavicle.  A  still  better 
view  is  obtained  if  the  clavicle,  or  at  least  its  sternal  half,  is  also  removed.  By  this  procedure  we 
expose  the  first  rib,  and  consequently  the  dividing-line  between  the  neck  and  the  thorax,  since  the 
dome  of  the  pleura  with  the  contained  apex  of  the  lung  extends  upward  beyond  the  first  rib. 
Passing  downward  upon  the  right  side,  we  come  to  the  innominate  artery,  which  divides  into  the 
right  common  carotid  and  the  right  subclavian  behind  the  upper  margin  of  the  sternum.     LI  his 


70  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  27. — The  supraclavicular  region.     The  sternocleidomastoid  and  the  infrahyoid  muscles  have  been  removed. 
Fig.  28. — The  infraclavicular  region. 


division  takes  place  approximately  behind  the  right  sternoclavicular  articulation. — Ed.]  Upon 
the  left  side  these  two  vessels  arise  separately  from  the  arch  of  the  aorta  behind  the  junction  of  the 
first  rib  with  the  sternum  in  this  region;  they  are  also  covered  by  both  portions  of  the  sterno- 
cleidomastoid muscle,  by  the  sternoclavicular  articulation,  and  by  the  origins  of  the  sternohyoid 
and  sternothyroid  muscles.  The  common  carotid  artery  gives  off  no  branches,  and,  after  crossing 
beneath  the  omohyoid  muscle,  appears  beneath  the  inner  margin  of  the  sternocleidomastoid. 
The  subclavian  artery  passes  out  of  the  thoracic  aperture  to  the  inner  side  of  the  dome  of  the 
pleura  (which  encloses  the  apex  of  the  lung),  describes  an  outward  curve,  the  convexity  of  which 
is  directed  upward,  passes  behind  the  anterior  scalene  muscle,  and  runs  over  the  first  rib  in  the 
subclavian  groove  (the  lower  broad  portion  of  the  scalene  slit).  The  artery  consequently  reaches 
the  supraclavicular  fossa,  where  its  pulsations  may  be  more  or  less  distinctly  felt,  and  then  passes 
beneath  the  middle  of  the  clavicle  and  the  subclavius  muscle,'  below  which  it  is  known  as  the 
axillary  artery.  With  the  exception  of  the  posterior  scapular,  all  of  the  branches  of  the  sub- 
clavian artery  are  given  off  before  the  vessel  passes  between  the  anterior  and  middle  scalene 
muscles.  These  branches  lie  upon  the  small  portion  of  the  artery  which  is  deeply  situated  behind 
the  clavicular  portion  of  the  sternocleidomastoid  muscle  and  are  covered  by  the  subclavian  vein 
and  its  junction  with  the  internal  jugular.     The  branches  are: 

1.  The  vertebral  artery  (see  page  34). 

2.  The  internal  mammary  artery  (see  page  93). 

3.  The  thyroid  axis,  which  immediately  divides  into: 

(a)  The  inferior  thyroid  artery.  This  is  usually  the  largest  division  of  the  thyroid  axis.  It 
runs  upward  and  then  inward  upon  the  vertebral  column  behind  the  common  carotid  artery, 
supplies  the  pharynx,  esophagus,  trachea,  and  larynx  (inferior  laryngeal  artery),  and  reaches  the 
posterior  surface  of  the  thyroid  gland. 

(b)  The  ascending  cervical,  which  is  often  very  small  and  runs  upward  upon  the  origins  of 
the  scalene  muscles. 

(c)  The  transversalis  colli,  which  passes  through  the  supraclavicular  fossa  transversely 
across  the  scalene  muscles  and  in  front  of  the  brachial  plexus  to  the  trapezius  muscle. 

(d)  The  suprascapular,  which  is  frequently  an  independent  branch  of  the  subclavian  artery. 
This  vessel  runs  slightly  downward  to  the  upper  margin  of  the  scapula  and  is  concealed  beneath 
the  clavicle ;  it  passes  over  the  transverse  ligament  of  the  scapula  to  reach  the  supraspinous  fossa 
and  then  skirts  the  neck  of  the  bone  and  enters  the  infraspinous  fossa.  It  supplies  the  supra- 
spinatus  and  infraspinatus  muscles  and  anastomoses  with  the  subscapular  branch  of  the  axillary 
artery  (see  page  74  and  Fig.  30). 

4.  The  costocervical  axis,  a  short  trunk  which  passes  posteriorly  and  divides  into: 

(a)  The  superior  intercostal  artery  (see  page  96)  for  the  first  one  or  two  intercostal  spaces,  and 

(b)  The  deep  cervical  artery,  which  runs  posteriorly  over  the  neck  of  the  first  rib  to  supply 
the  deep  muscles  of  the  neck  and  back. 


Fig.  27. 


Superior  thyroid  vein 

Internal  jugular  vein 
Common  carotid  artery 

Vagus  nerve 

Inferior  thyroid  artery 

Bulb  of  internal  jugular  vein 


Left  innominate  vein 


Internal   mammary  artery 
Internal  mammary  vein 

First  rib 


_-  Fourth  cervical  nerve 


M.  scalenus  medius 


Phrenic  nerve 
Vertebral  artery 
M.  scalenus  ant. 
Ascending  cervical  artery 


Eighth  cervical  nerve 
Transversalis  colli  artery 
P'irst  thoracic  nerve 

Posterior  scapular  artery 

External  jugular  vein 

Suprascapular  artery 

Subclavian  artery 

Subclavian   vein 


M.  subclavius         Acromio-thoracic  artery 
Clavicle  Brachial  plexus  Costo-coracoid  membrane 


Fig.  28. 


Thoracic  branch   of    acromiothoracic  artery 

Axillary '  vein 


/JfW.  pectoralis  minor 

'•Anterior  thoracic  nerves 
;       Cephalic  vein 
Axillary  artery 


THE  NECK.  •  71 

As  the  subclavian  artery  leaves  the  scalene  triangle,  or  while  it  is  still  within  this  space,  it 
gives  off 

5.  The  posterior  scapular  artery,  which  passes  between  the  trunks  of  the  brachial  plexus  and 
runs  parallel  to  the  transversalis  colli  (by  which  vessel  it  is  occasionally  replaced)  beneath  the 
insertion  of  the  levator  anguli  scapulae,  where  it  subdivides  into  an  ascending  and  a  descending 
branch.* 

In  ligating  the  subclavian  artery  as  it  passes  over  the  first  rib,  the  posterior  scapular,  the 
suprascapular,  and  the  transversalis  colli  arteries  must  be  carefully  avoided.  Special  attention 
must  also  be  paid  to  the  external  jugular  vein,  which  should  be  divided  between  two  ligatures  to 
avoid  the  entrance  of  air  emboli.  The  deeper  we  penetrate  in  this  region,  the  more  it  behooves 
us  to  remember  that  the  pleural  sac  projects  above  the  superior  aperture  of  the  thorax  (see 
page  101). 

The  internal  jugular  vein  is  external  to  the  common  carotid  artery  and,  as  in  the  carotid 
triangle,  partly  overlies  this  structure;  behind  the  sternoclavicular  articulation  it  unites  with  the 
subclavian  vein  to  form  the  innominate  vein.  The  lower  more  or  less  dilated  portion  of  the  in- 
ternal jugular  vein  is  known  as  the  inferior  bulb  0}  the  vein.  The  subclavian  vein  lies  in  front  of 
and  somewhat  below  the  artery  of  the  same  name  (in  Fig.  27  the  outer  portion  of  the  vein  has  been 
displaced  slightly  upward),  the  two  vessels  being  separated  by  the  insertion  of  the  anterior  scalene 
muscle.  This  vein  receives  the  external  jugular,  the  anterior  jugular  (frequently  a  tributary  of 
the  external  jugular),  the  acromiothoracic,  the  suprascapular,  and  the  posterior  scapular  veins. 

The  cervical  plexus,  formed  by  the  anterior  divisions  of  the  four  upper  cervical  nerves,  lies 
upon  the  origins  of  the  muscles  forming  the  floor  of  the  lateral  cervical  region  and  is  covered  by  the 
sternocleidomastoid  muscle. 

The  small  anterior  division  of  the  first  cervical  nerve  communicates  particularly  with  the 
superior  cervical  ganglion  and  forms  a  loop  with  the  second  cervical  nerve,  from  which  the  muscles 
of  the  neck  receive  their  branches.  Muscular  branches  are  also  given  off  by  the  second  cervical 
nerve  (to  the  levator  anguli  scapulas,  for  example).  This  nerve,  and  frequently  the  third  cervical 
as  well,  gives  off  the  fine  filaments  which  pass  anteriorly  and  unite  with  the  descendens  hypoglossi 
to  form  the  ansa  hypoglossi.  The  occipitalis  minor  (see  page  68)  usually  arises  from  the  loop 
connecting  the  second  with  the  third  cervical  nerve.  The  auricularis  magnus  (see  page  68)  and 
the  superficial  colli  (see  page  68)  are  given  off  from  the  third  or  from  the  loop  connecting  the 
third  with  the  fourth  cervical  nerve;  the  supraclavicular  nerves  are  given  off  from  the  fourth  or 
from  the  third  and  fourth  cervical  nerves,  while  the  phrenic  (see  page  104)  usually  originates 
exclusively  from  the  fourth  cervical.  There  is  a  communicating  branch  connecting  the  fourth 
cervical  nerve  with  the  brachial  plexus,  the  large  roots  of  which  may  be  seen  in  the  upper 
portion  of  the  scalene  triangle  above  the  subclavian  artery.  The  phrenic  nerve  runs  downward 
upon  the  anterior  scalene  muscle  and  enters  the  thoracic  cavity  by  passing  between  the  sub- 
clavian artery  and  vein  (see  Plate  8). 

*The  author's  nomenclature  and  description  of  the  branches  of  the  subclavian  artery  differ  considerably  from 
most  English  versions.  This  is  not  of  great  importance,  however,  when  one  considers  the  wide  variations  exhibited  by 
the  structures  themselves. — Ed. 


72  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

QUESTIONS. 

How  may  the  external  jugular  vein  be  made  distinctly  visible  in  the  neck  of  the  living  subject? 

Where  may  the  pulsations  of  the  common  carotid  and  subclavian  arteries  be  felt  ? 

Where  is  the  most  favorable  place  for  making  compression  upon  the  subclavian  artery? 

What  nerve  is  to  be  carefully  avoided  in  the  ligation  of  the  subclavian  artery  ? 

What  bone  serves  as  a  landmark  in  the  exposure  of  the  lingual  artery  in  the  neck  ? 

What  relations  exist  between  the  face  and  the  submaxillary  lymphatic  glands  ? 

What  situation  is  best  adapted  for  opening  the  larynx  ?    What  situation  is  least  adapted  ? 

Where  may  abscesses  rupture  which  originate  in  the  posterior  laryngeal  wall  and  extend  poste- 
riorly ? 

Where  is  high  tracheotomy  performed?  Where  is  low  tracheotomy  performed?  Which  opera- 
tion is  more  easily  performed  and  why  ? 

What  anomaly  of  the  thyroid  gland  may  complicate  the  performance  of  high  tracheotomy  ? 

How  may  the  esophagus  be  exposed  in  the  neck  and  what  nerve  is  thereby  endangered  ? 

What  organs  may  be  compressed  by  enlargements  of  the  thyroid  gland  ? 

What  nerve  may  be  injured  in  thyroidectomy  and  what  will  be  the  result  ? 

Where  are  the  important  groups  of  the  cervical  lymphatic  glands  situated  ? 

Where  should  a  stethoscope  be  placed  to  hear  venous  murmurs  in  the  internal  jugular  vein  ? 

What  artery  may  be  ligated  in  this  situation  ? 


THE  UPPER  EXTREMITY. 

THE  SHOULDER. 

The  shoulder  is  bounded  above  by  the  clavicle,  by  the  acromion,  and  by  a  line  drawn  from 
the  acromion  to  the  spinous  process  of  the  seventh  cervical  vertebra.  The  lower  boundary  of  this 
region  is  formed  by  the  insertions  of  the  pectoralis  major  and  latissimus  dorsi  muscles.  The 
clavicular  portion  of  the  pectoralis  major  arises  from  the  sternal  extremity  of  the  clavicle,  the 
sternal  portion  from  the  anterior  surface  of  the  sternum  and  of  the  six  upper  ribs,  and  the  ab- 
dominal portion  (inconstant)  from  the  anterior  layer  of  the  sheath  of  the  rectus  abdominis ;  the 
tendon  of  the  pectoralis  major  is  inserted  into  the  anterior  bicipital  ridge  of  the  humerus.  The 
latissimus  dorsi  arises  from  the  spinous  processes  of  the  lower  six  dorsal  and  of  all  of  the  lumbar 
and  sacral  vertebras,  from  the  crest  of  the  ilium,  from  the  posterior  lamella  of  the  lumbar  fascia, 
and  from  the  outer  surfaces  of  the  lower  ribs ;  the  tendon  of  the  latissimus  dorsi  is  inserted  into  the 
posterior  bicipital  ridge.  The  characteristic  prominence  of  the  shoulder  is  formed  by  the  head 
of  the  humerus  and  by  the  overlying  deltoid  muscle,  which  arises  from  the  acromial  end  of  the 
clavicle,  from  the  acromion,  from  the  spine  of  the  scapula,  and  from  the  infraspinous  fascia  and  is 
inserted  into  the  deltoid  tubercle  of  the  humerus.  Through  the  deltoid  muscle  may  be  more  or 
less  distinctly  felt  the  head  oj  the  humerus,  with  the  greater  and  lesser  tuberosities,  and  the  inter- 
vening bicipital  groove  containing  the  long  tendon  of  the  biceps.  The  bicipital  groove  deter- 
mines the  direction  of  Langenbeck's  incision  for  resection  of  the  shoulder-joint.     To  the  inner 


THE   SHOULDER.  7_ 

side,  covered  by  the  edge  of  the  deltoid  muscle,  may  be  felt  the  coracoid  process.  This  is  situated 
slightly  to  the  outer  side  of  the  groove,  between  the  pectoralis  major  and  the  deltoid,  which  contains 
the  cephalic  vein  and  widens  out  as  it  passes  up  toward  that  portion  of  the  clavicle  which  is  more 
or  less  free  from  muscular  attachments.  In  this  situation  is  the  infraclavicular  fossa,  the  region 
for  ligating  the  first  portion  of  the  axillary  artery.  In  lean  individuals  the  sharp  margin  of  the 
costocoracoid  ligament  may  be  palpated  in  this  fossa  as  it  runs  toward  the  coracoid  process.  At 
the  acromial  end  of  the  clavicle  is  the  acromioclavicular  articulation,  which  feels  like  a  short 
narrow  groove  running  in  a  sagittal  direction.  The  parts  which  have  been  named  should  be 
palpated  in  normal  individuals,  so  that  the  changed  relations  present  in  dislocations  of  the 
shoulder-joint  may  be  recognized  with  certainty. 

The  Anterior  Region  of  the  Shoulder.— After  dividing  the  skin,  the  platysma,  the  ends  of 
the  supraclavicular  nerves,  and  the  thin  fascia  covering  the  groove  between  the  pectoralis  major 
and  the  deltoid,  we  may  easily  find  the  cephalic  vein,  which  runs  upward  from  the  external 
bicipital  groove  accompanied  by  the  humeral  branch  of  the  acromiothoracic  artery  (see  page  95); 
it  passes  inward  above  the  tendon  of  the  pectoralis  minor,  perforates  the  costocoracoid  membrane, 
and  empties  into  the  axillary  vein.  If  the  deep  fascia  is  removed,  the  narrow  space  between  the 
upper  border  of  the  pectoralis  minor  and  the  subclavius  muscle  is  exposed.  The  pectoralis  minor 
arises  from  the  outer  surfaces  of  the  second  to  the  fifth  ribs  and  is  inserted  into  the  coracoid 
process;  the  subclavius  arises  from  the  junction  of  the  first  rib  with  its  cartilage  and  is  inserted 
into  the  under  surface  of  the  acromial  extremity  of  the  clavicle  (see  Fig.  28).  If  we  follow  the 
cephalic  vein,  we  come  to  the  axillary  vein.  To  the  outer  side  of  this  vein  are  the  cords  of  the 
brachial  plexus,  and  between  these  two  structures  and  somewhat  posteriorly  is  the  axillary  artery 
just  after  it  has  passed  over  the  first  rib.  This  is  the  usual  situation  for  the  ligation  of  this  vessel. 
In  order  to  expose  the  artery  the  plexus  must  be  displaced  outward  and  the  vein  inward.  The 
structures  endangered  are  the  acromiothoracic  artery  (acromial,  thoracic,  and  descending 
branches)-,  and  the  anterior  thoracic  nerves  which  supply  the  pectoralis  major  and  minor  muscles. 
An  independent  thoracic  branch  (the  superior  thoracic)  is  occasionally  given  off  by  the  axillary 
artery.  The  vessels  and  nerves  pass  beneath  the  clavicle,  the  position  of  the  artery  corresponding 
to  about  the  middle  of  the  bone.  The  relation  of  the  vessels  and  nerves  to  the  clavicle  explains 
the  fact  that  in  fractures  of  this  bone  they  may  be  more  or  less  lacerated  or  compressed  by  the 
downward  displacement  of  the  acromial  fragment.  [Laceration  or  compression  of  the  nerves 
and  vessels  following  fractures  is  much  less  frequent  than  might  be  supposed,  owing  to  the  fact 
that  the  subclavius  muscle  acts  as  a  cushion. — Ed.]  The  plexus  is  more  frequently  involved  in 
these  injuries  than  are  the  vessels.  As  the  nerve-trunks  are  nearest  to  the  shoulder-joint,  they 
are  the  first  structures  to  be  compressed  in  the  subcoracoid  dislocation,  in  which  the  head  of  the 
humerus  is  drawn  inward  and  presses  them  against  the  ribs.  This  dislocation  may  also  injure 
the  circumflex  nerve  (see  page  75  and  Fig.  30)  which  runs  around  the  surgical  neck  of  the  humerus. 
A  corresponding  compression  of  the  vessels  and  nerves  may  also  be  observed  in  those  fractures  of 
the  surgical  neck  of  the  humerus  in  which  the  upper  end  of  the  lower  fragment  is  so  frequently 
displaced  inward  and  the  arm  is  held  in  a  position  of  abduction.  As  the  vessels  are  situated  at  a 
greater  distance  from  the  head  of  the  humerus,  they  are  less  likely  to  be  involved  than  are  the 
nerves. 


74  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

Fig.  29. — The  axilla  and  the  lateral  thoracic  wall. 

Axilla. — At  the  lower  border  of  the  subclavius  muscle  the  vessels  and  nerves  for  the  upper 
extremity  pass  into  the  space  known  as  the  axillary  cavity.  This  cavity  is  situated  above  the 
axillary  fossa,  formed  by  the  skin,  and  is  a  pyramidal  space  containing  vessels,  nerves,  fat,  and 
lymphatic  glands.  We  differentiate  an  apex,  situated  at  the  coracoid  process  [in  most  English 
text-books  the  apex  is  said  to  be  between  the  first  rib,  clavicle,  and  upper  border  of  the 
scapula,  thus  opening  into  the  neck  and  permitting  the  passage  of  certain  structures  from  the 
neck  to  axilla. — Ed.],  a  base,  formed  by  the  skin  of  the  axillary  fossa,  and  four  walls.  The  anterior 
wall  is  formed  by  the  pectoralis  major  and  minor  muscles.  The  inner  wall  corresponds  to  the 
upper  portion  of  the  lateral  wall  of  the  thorax  with  the  overlying  serratus  magnus  muscle.  This 
muscle  arises  from  the  outer  surfaces  of  the  upper  eight  or  nine  ribs  and  is  inserted  into  the 
vertebral  border  of  the  scapula.  Eight  or  ten  lymphatic  glands  are  more  or  less  closely  related 
with  this  wall  in  the  neighborhood  of  the  three  upper  intercostal  spaces  (see  Fig.  29) ;  they  are 
connected  with  the  lymphatic  vessels  of  the  breast  and  of  the  arm.  Great  care  must  be  exercised 
in  removing  these  glands,  as  they  are  closely  related  to  the  vessels  and  are  particularly  apt  to  be 
adherent  to  these  structures  when  degenerated.  The  surgeon  has  to  deal  with  these  glands  par- 
ticularly in  carcinoma  of  the  female  breast  (see  page  95).  The  posterior  wall  is  formed  by  the 
subscapularis  and  the  teres  major  muscles  which  overlie  the  anterior  surface  of  the  scapula.  The 
subscapularis  arises  from  the  subscapular  fossa  and  is  inserted  into  the  lesser  tuberosity  of  the 
humerus;  the  teres  major  arises  from  the  axillary  border  of  the  scapula  and  the  infraspinous 
fascia  and  is  inserted,  together  with  the  tendon  of  the  latissimus  dorsi,  into  the  posterior  bicipital 
ridge.  The  outer  wall  is  formed  by  the  shoulder-joint  and  by  the  surgical  neck  of  the  humerus; 
these  structures  are  covered  by  the  short  head  of  the  biceps  and  by  the  coracobrachialis. 

The  axillary  artery  is  in  relation  first  with  the  posterior  and  then  with  the  outer  wall  of  the 
axillary  cavity.  The  pulsations  of  the  vessel  may  be  distinctly  felt  to  the  inner  side  of  the  promi- 
nence caused  by  the  coracobrachialis  muscle ;  this  is  the  situation  in  which  the  artery  may  be  most 
safely  ligated  by  elevating  the  arm  and  keeping  close  to  the  border  of  the  muscle.  The  vessel  is 
comparatively  close  to  the  shoulder-joint  and  is  sometimes  torn  across  in  dislocations  or  in  attempts 
at  their  forcible  reduction.     The  branches  of  the  axillary  artery  are: 

1.  The  acromiothoracic  (see  page  95). 

2.  The  subscapular,  which  arises  from  about  the  middle  of  the  axillary  and  consequently  at 
the  mid-point  between  the  clavicle  and  the  lower  border  of  the  pectoralis  major  muscle,  in  which 
latter  situation  the  axillary  becomes  the  brachial.  The  subscapular  artery  divides  into  two  chief 
branches,  the  dorsalis  scapulae  and  the  thoracicodorsalis  [the  continuation  of  the  subscapular]. 
The  dorsalis  scapulce  runs  over  the  external  border  of  the  scapula  to  the  dorsal  surface  of  this  bone, 
supplies  the  surrounding  muscles,  and  anastomoses  freely  with  the  suprascapular  branch  of  the 
subclavian.  This  is  the  main  path  for  the  collateral  circulation  when  the  blood-current  in  the 
axillary  artery  is  interfered  with  or  when  this  vessel  is  ligated.  The  thoracicodorsalis  is  the  largest 
vessel  of  the  lateral  thoracic  wall  (see  page  96).  It  runs  down  the  axillary  border  of  the  scapula, 
under  cover  of  the  edge  of  the  latissimus  dorsi,  and  particularly  supplies  the  teres  major,  the 
latissimus  dorsi,  and  the  serratus  magnus  muscles. 


Fig.  29. 


Musculocutaneous  nerve 
Axillary  artery 
Brachial  plexus      i  Axillary  vein 


Posterior  circumflex  artery 

Circumflex  nerve 

Median  nerve 

;   Ulnar  nerve 

Musculospiral  nerve 


M.  pectoralis  minor 


Axillary  lymphatic 
glands 


Long  thoracic  artery 
and  vein 


Internal  cutaneous  nerve 


Subscapular  artery 

Lesser  int.  cut.   nerve 
Lateral  cut.  branch  of 

second  intercost.  nerve 
Dorsalis  scapulae  artery 

Thoracicodorsalis  artery 


M.  latissimus  dorsi 
Long  subscapular  nerve 

Long  thoracic  nerve 
Lateral  cut.  branch  of 
third  intercostal  nerve 


Thoracicoepigastric  vein 


"'«** 


THE   SHOULDER.  *- 

3.  The  long  thoracic,  an  inconstant  branch,  which  arises  above  the  subscapular  (see  page 
95)  and  is  situated  in  front  of  the  thoracic  dorsalis. 

4.  The  anterior  circumflex,  a  small  branch  which  runs  outward  over  the  anterior  surface  of 
the  neck  of  the  humerus. 

5.  The  posterior  circumflex,  a  large  branch  which  arises  beside  the  preceding  one,  passes 
through  the  quadrangular  space  (see  page  76)  close  to  the  bone  to  run  posteriorly  with  the  cir- 
cumflex nerve  and,  like  it,  to  particularly  supply  the  deltoid  muscle.  As  the  vessel  is  closely 
related  to  the  neck  of  the  humerus,  it  must  be  carefully  treated  in  resection  of  the  shoulder- joint. 
If  the  operation  is  strictly  subperiosteal,  the  elevator  being  always  directed  toward  the  bone,  the 
vessel  will  escape  injury. 

The  axillary  vein,  like  the  subclavian,  is  situated  in  front  and  to  the  inner  side  of  the  artery; 
it  consequently  covers  the  artery  to  a  varying  extent,  dependent  upon  the  degree  of  its  distention. 
It  is  only  in  exceptional  cases  that  the  axillary  vein  is  double. 

Brachial  Plexus.— Just  beneath  the  clavicle  the  trunks  of  the  brachial  plexus,  with  the 
exception  of  a  few  small  branches,  are  situated  to  the  outer  side  of  the  vessel.  Beneath  the 
pectoralis  minor  muscle  these  trunks  form  three  cords  which  are  so  arranged  about  this  portion 
of  the  artery  that  we  may  differentiate  an  outer,  an  inner,  and  a  posterior  cord.  The  outer  and 
inner  cords  supply  chiefly  the  skin  and  muscles  of  the  flexor  surface,  while  the  posterior  cord 
supplies  the  extensor  surface.  A  more  detailed  study  of  the  axilla  shows  that  the  outer  cord 
gives  off  the  musculocutaneous  nerve  and  the  outer  head  0}  the  median.  From  the  inner  cord 
arises  the  inner  head  0}  the  median  which,  together  with  the  outer  head,  surrounds  the  axillarv 
artery  like  the  prongs  of  a  fork;  the  inner  cord  also  gives  off  the  ulnar,  the  internal  cutaneous,  and 
the  lesser  internal  cutaneous  nerves.  From  the  posterior  cord  arise  the  circumflex,  the  musculo- 
spiral,  and  the  subscapular  nerves. 

Of  the  other  branches  of  the  brachial  plexus  there  is  one  which  is  of  particular  importance 
from  a  surgical  standpoint;  this  is  the  long  thoracic,  the  motor  nerve  of  the  serratus  magnus 
muscle.  It  lies  directly  upon  the  serratus  magnus,  in  association  with  the  thoracicodorsalis 
artery,  and  is  covered  by  the  edge  of  the  latissimus  dorsi ;  it  is  not  particularly  exposed  to  injury 
in  operations  in  the  axillary  cavity.  The  comparatively  superficial  long  or  middle  subscapular 
nerve  running  to  the  latissimus  dorsi  is  more  easily  injured,  and  its  division  is  followed  by  paralysis 
of  this  muscle.  [Note:  The  long  thoracic  nerve  is  related  to  the  thoracico-dorsal  artery  only  in 
the  lower  part  of  its  course;  the  long  (middle)  subscapular  is  in  close  relation  to  this  vessel. — Ed.] 
The  other  two  subscapular  nerves  supply  the  teres  major  and  the  subscapularis  muscles  and  are 
more  deeply  situated.  The  suprascapular  nerve,  which  runs  through  the  suprascapular  notch  to 
the  dorsal  surface  of  the  scapula  and  supplies  the  supraspinatus  and  infraspinatus  muscles,  is 
more  rarely  divided  by  the  knife  of  the  surgeon;  the  nerve  filaments  supplying  the  levator  anguli 
scapulas  and  the  rhomboid  muscles  are  also  rarely  injured. 

Posterior  Region  of  the  Shoulder.— The  arrangement  of  the  muscles  in  this  situation 
forms  a  typical  topographic  picture  which  is  of  importance  for  the  exposure  of  the  deep  vessels 
and  nerves  of  this  region.  The  deltoid  and  teres  major  muscles  have  been  previously  described. 
The  supraspinatus  muscle  arises  from  the  supraspinous  fossa;  it  passes  beneath  the  acromion 
and  the  trapezius  muscle  and  is  attached  to  the  greater  tuberosity  of  the  humerus.     The  infra- 


76  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

Fig.  30. — A  posterior  view  of  the  shoulder  with  the  quadrangular  and  triangular  spaces. 

spinatus  muscle,  partly  covered  by  the  deltoid,  passes  from  the  infraspinous  fossa  to  the  greater 
tuberosity  of  the  humerus.  The  teres  minor,  in  relation  with  the  lower  border  of  the  preceding 
muscle,  runs  from  the  axillary  margin  of  the  scapula  to  the  greater  tuberosity  of  the  humerus; 
its  lower  border  is  approximately  parallel  to  the  upper  border  of  the  teres  major  muscle.  Since 
both  of  these  muscles  are  crossed  by  the  long  tendon  of  the  triceps  (which  lies  behind  the  teres 
major,  but  in  front  of  the  teres  minor),  as  shown  in  Fig.  30,  it  will  be  seen  that  two  spaces  are 
formed,  a  quadrangular  space  and  a  triangular  space. 

1.  The  quadrangular  space  is  bounded  by  the  neck  of  the  humerus,  by  the  teres  minor, 
by  the  teres  major,  and  by  the  long  head  of  the  triceps  (see  Fig.  30).  Within  this  space,  the 
axillary  artery  may  be  exposed  from  behind;  the  posterior  circumflex  artery  and  the  circumflex 
nerve  may  also  be  seen  as  they  pass  into  the  substance  of  the  deltoid  from  the  inner  surface  of  the 
muscle  (see  page  75). 

2.  The  triangular  space  is  bounded  by  the  long  head  of  the  triceps  and  by  the  teres  major 
and  minor  muscles.  In  this  space  may  be  seen  one  of  the  two  terminal  divisions  of  the  sub- 
scapular artery,  the  dorsalis  scapulae  (see  page  74).  This  vessel  turns  around  the  axillary  border 
of  the  scapula  to  its  posterior  surface,  where  it  is  covered  by  the  infraspinatus  muscle,  and  runs 
upward  to  anastomose  with  the  suprascapular  artery  below  the  root  of  the  acromion  (see  page  74). 
This  anastomosis  forms  an  important  collateral  path  after  occlusion  of  the  axillary  artery.  If -the 
axillary  artery  is  followed  downward  along  the  inner  side  of  the  humerus,  it  will  be  seen  to  emerge 
as  the  brachial  artery  below  the  united  tendons  of  the  latissimus  dorsi  and  teres  major  muscles. 
In  the  triangular  slit  between  the  humerus,  the  long  tendon  of  the  triceps,  and  the  external  head 
of  the  triceps,  the  brachial  artery  gives  off  the  superior  profunda,  which  runs  posteriorly  and 
accompanies  the  musculospiral  nerve. 

Shoulder-joint  (Fig.  31). — This  joint  has  the  widest  range  of  motion  of  any  joint  in  the  body. 
The  articulation  is  formed  by  the  head  of  the  humerus  and  the  glenoid  cavity  of  the  scapula.  The 
humeral  head  is  covered  by  cartilage  and  the  articular  surface  of  the  glenoid  cavity  is  enlarged 
(deepened)  by  the  glenoid  ligament.  As  a  consequence  of  the  incongruity  between  the  two 
articular  surfaces,  the  head  of  the  humerus  projects  far  beyond  the  edge  of  the  glenoid  cavity. 

The  lax  capsular  ligament  passes  down  from  the  circumference  of  the  glenoid  cavity  and  is 
attached,  anteriorly,  to  the  anatomic  neck  of  the  humerus  (i.  e.,  the  groove  bounding  the  articular 
cartilage);  posteriorly,  to  the  bone  somewhat  below  the  anatomic  neck.  It  bridges  over  the 
bicipital  groove  (sulcus  intertubercularis)  which  lodges  the  long  tendon  of  the  biceps.  This 
structure  is  enclosed  in  a  tubular  reflection  of  the  synovial  membrane,  the  vagina  mucosa  inter- 
tubercularis, which  is  the  deepest  portion  of  the  joint  when  the  body  is  held  erect  and  which  is 
often  markedly  distended  by  exudate  when  the  shoulder-joint  is  inflamed.  The  greater  and 
lesser  tuberosities  are  outside  of  the  joint.  The  synovial  membrane  is  also  reflected  beneath  the  in- 
sertion of  the  subscapularis  muscle,  forming  the  bursa  mucosa  sub  scapular  is.  This  is  the  weakest 
portion  of  the  capsular  ligament ;  it  is  the  place  where  the  head  of  the  bone  leaves  the  capsule 
in  the  common  subcoracoid  dislocation.  A  second  weak  place  is  to  be  found  in  the  deepest  part 
of  the  joint  between  the  margins  of  the  subscapularis  and  the  teres  minor  muscles  (see  Fig.  30).. 


Fig.  )o. 


Deltoid  muscle  <- 


M.  teres  minor 


Weak  place  in  capsular 
ligament 
Circumflex  nerve 

Posterior  circumflex  artery 

Humerus 


External  head  of 
triceps  muscle 


M.  infraspinatus 

-Suprascapular  nerve 

Anastomosis  between  dorsalis 
scapulae  and  suprascapular  arteries. 


%£-_ Dorsalis  scapulae  artery 

Mp M.  supscapularis 

"JM      Thoracico-dorsalis  artery 

Subscapular  artery 

M.  teres  major 

Long  head  of  triceps  muscle 
M.  latissimus  dorsi 


THE    UPPER  ARM.  77 

Although  almost  the  entire  capsule  is  surrounded  and  strengthened  by  the  insertions  of  muscles, 
this  place  is  not  covered  by  any  muscle,  and  through  it  occurs  the  dislocation  which  is  second 
in  frequency,  the  subglenoid  or  axillary  dislocation. 

A  large  bursa,  which  does  not  communicate  with  the  joint,  is  also  situated  beneath  the 
deltoid  muscle  (subdeltoid  bursa)  and  may  extend  beneath  the  acromion.  This  bursa,  when 
diseased,  may  be  mistaken  for  an  effusion  into  the  shoulder-joint.  The  capsular  ligament 
possesses  but  one  important  strengthening  band,  the  coracohumeral  ligament,  which  arises  from 
the  outer  edge  of  the  coracoid  process  and  radiates  in  the  capsule  toward  the  greater  tuberosity 
of  the  humerus.  The  joint  is  well  protected  above  by  the  strong  coracoacromial  ligament,  which 
extends  from  the  acromion  to  the  posterior  surface  of  the  coracoid  process.  It  prevents  the  head 
of  the  bone  from  slipping  upward,  this  displacement  being  possible  only  when  a  fracture  of  the 
overhanging  acromion  is  present. 

THE  UPPER  ARM. 

Upon  the  anterior  or  flexor  surface  of  the  arm  the  prominence  of  the  biceps  muscle  may  be 
easily  palpated;  to  either  side  of  this  prominence  are  the  outer  and  inner  bicipital  grooves  respec- 
tively [indicating  the  inner  and  outer  edges  of  this  muscle.  The  term  "bicipital  groove"  is 
usually  applied  by  English  authors  to  the  bony  groove  in  the  humerus  which  contains  the 
long  tendon  of  the  biceps. — Ed.].  The  pulsations  of  the  brachial  artery  may  be  palpated  at  the 
inner  margin  of  the  muscle.  The  bicipital  prominence  becomes  more  pointed  as  it  passes 
upward,  and  finally  disappears  beneath  the  edge  of  the  pectoralis  major  muscle  at  the  so-called 
anterior  axillary  fold.  This  portion  corresponds  to  the  short  head  of  the  biceps  and  to  the 
coracobrachialis  muscles.  High  up  to  its  inner  side  may  be  seen,  or  at  least  felt,  the  pulsations 
of  the  axillary  artery.  This  is  the  place  of  election  for  the  ligation  of  this  vessel  (see  page  73). 
In  the  upper  portion  of  the  internal  bicipital  groove  the  chief  branches  of  the  brachial  plexus 
accompany  the  artery  and  may  be  palpated  for  a  varying  distance  downward  into  the  arm. 

The  comparatively  thin  deep  fascia  of  the  arm  sends  off  the  external  and  internal  inter- 
muscular septa,  which  are  attached  to  the  external  and  internal  condyloid  ridges  respectively  and 
extend  downward  as  far  as  the  epicondyles.  They  separate  the  biceps,  brachialis  anticus,  and 
coracobrachialis  muscles,  which  are  situated  anteriorly,  from  the  posterior  extensor  mass  of  the 
triceps  muscle.  The  biceps  muscle  arises  by  a  long  head  from  the  supraglenoid  tubercle  within 
the  shoulder- joint  (see  page  76),  and  by  a  short  head  from  the  apex  of  the  coracoid  process;  it 
inserts  into  the  tuberosity  of  the  radius.  The  brachialis  anticus  muscle,  situated  beneath  the  biceps, 
arises  from  the  anterior  aspect  [f,  e.,  inner  and  outer  surfaces. — Ed.]  of  the  humerus,  below  the 
insertion  of  the  deltoid  muscle,  and  from  the  intermuscular  septa,  and  is  inserted  into  the  coronoid 
process  of  the  ulna.  The  origin  of  the  coracobrachialis  muscle  is  from  the  coracoid  process  in 
common  with  the  short  head  of  the  biceps,  and  its  insertion  is  at  about  the  middle  of  the  internal 
border  of  the  humerus.  The  long  head  of  the  triceps  arises  from  the  infraglenoid  tubercle  of  the 
scapula;  the  inner  head  arises  from  the  posterior  surface  of  the  humerus  below  the  musculospiral 
groove;  the  outer  head  commences  above  the  musculospiral  groove,  which  it  bridges  over,  and 
arises  from  the  outer  surface  of  the  bone  and  from  the  external  intermuscular  septum.  These 
three  heads  are  inserted  into  a  common  tendon  which  is  attached  to  the  olecranon. 


78  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

Fig.  31. — A  model  of  the  shoulder-joint  and  its  bursae.  The  two  bursae  communicating  with  the  articular  cavity 
as  well  as  the  joint  itself  are  colored  blue.  The  non-communicating  subdeltoid  bursa  is  represented  in  red.  (From 
a  Berlin  model.) 

Fig.  32. — A  cross-section  through  the  middle  of  the  arm  (hardened  in  formalin). 

In  the  internal  bicipital  groove,  about  at  the  junction  of  the  lower  with  the  middle  third  of 
the  arm,  there  is  an  opening  in  the  deep  fascia,  which  is  known  as  the  hiatus  basilicus,  for  the 
passage  of  the  basilic  vein  and  the  internal  cutaneous  nerve.  In  the  external  bicipital  groove  the 
cephalic  vein  runs  upon  the  deep  fascia  (see  page  73). 

The  brachial  artery  runs  beneath  the  deep  fascia  in  the  internal  bicipital  groove;  it  is  ac- 
companied by  two  veins,  the  inner  of  which  receives  the  basilic  vein.  Higher  up,  the  venae  comites 
unite  to  form  a  single  vein,  either  before  reaching  the  axilla  or,  more  rarely,  after  entering  into 
this  region.  Disregarding  the  muscular  branches,  of  which  the  bicipital  is  particularly  large,  the 
main  branches  of  the  brachial  are : 

1.  The  superior  profunda  artery,  which  accompanies  the  musculospiral  nerve  about  the 
posterior  surface  of  the  humerus,  in  the  musculospiral  groove,  between  the  outer  and  inner  heads 
of  the  triceps  muscle.  It  ends  at  the  outer  side  of  the  humerus,  where  it  is  accompanied  by  a 
cutaneous  branch  of  the  musculospiral  nerve,  and  descends  behind  the  external  intermuscular 
septum  to  reach  the  anastomotic  arch  above  the  olecranon  (rete  articulare  cubiti).  The  poste- 
rior articular  branch  of  this  vessel  runs  downward  in  the  posterior  portion  of  the  arm  in  the  sub- 
stance of  the  inner  head  of  the  triceps  muscle. 

2.  The  inferior  profunda  artery,  usually  a  long  vessel,  which  accompanies  the  ulnar  nerve 
to  the  olecranon,  where  it  empties  into  the  rete  cubiti. 

3.  The  anaslomotica  magna  artery,  which  arises  near  the  division  of  the  brachial  in  the  region 
of  the  elbow.  It  runs  transversely  inward  across  the  brachialis  anticus  muscle  and  passes  pos- 
teriorly to  the  rete  cubiti. 

The  median  nerve  is  the  most  superficial  of  the  three  chief  nerves  in  the  upper  arm.  At 
first  the  nerve  lies  to  the  outer  side  of  the  brachial  artery,  it  then  passes  in  front  of  the  vessel,  and, 
while  still  above  the  elbow,  takes  a  position  to  the  inner  side  of  the  artery.  The  nerve  con- 
sequently crosses  the  artery,  and  is  to  be  felt  lying  upon  the  vessel,  if  .the  panniculus  adiposus  is 
not  too  well  marked.  The  nerve  is  often  situated  beneath  the  artery,  particularly  in  those  cases 
of  so-called  high  division  of  the  brachial  in  which  the  artery  divides  in  the  upper  arm  into  two 
parallel  branches,  one  of  which  usually  runs  over  and  the  other  under  the  nerve.  If  the  artery 
first  exposed  is  comparatively  small,  and  if  it  lies  upon  the  median  nerve,  a  search  should  always 
be  made  for  a  second  artery.     The  median  nerve  gives  off  no  branches  in  the  upper  arm. 

The  ulnar,  the  second  great  nerve  of  the  arm,  lies  internal  to  the  artery,  but  gradually  becomes 
more  distant  from  the  vessel.  It  pierces  the  internal  intermuscular  septum  at  the  lower  third 
of  the  arm  and  reaches  the  space  between  the  internal  condyle  and  the  olecranon.  The  ulnar 
nerve  also  gives  off  no  branches  in  the  upper  arm. 

The  musculospiral,  the  motor  nerve  of  the  extensor  muscles,  is  at  first  behind  the  artery. 
It  enters  the  musculospiral  groove,  running  upon  the  surface  of  the  humerus  between  the  outer  and 
inner  heads  of  the  triceps  muscle,  and  at  the  lower  part  of  the  arm  passes  into  the  region  of  the 
elbow  between  the  supinator  longus  and  brachialis  anticus  muscles.     As  the  nerve  lies  directly 


Trapezoid  ligament 
Clavicle 


Coracoid  process 
Coraco-acromial  ligament 
Capsular  ligament 


Fig.  ;/. 


Conoid  ligament 
M.  supraspinatus 

Transverse  ligament  of  scapula 


Subdeltoid  bursa 


Humerus 
Tendon  of  long 
head  of  biceps 
Vagina  mucosa  intertubercularis 


M.   subscapularis 


Musculocutaneous  nerve 

Brachial  artery 

Median  nerve 

Basilic  vein 

Internal   cutaneous  nerve 

Ulnar  nerve  and  inferior 

profunda  artery 


Inner  head  of  triceps  muscle 


Long  head  of  triceps  muscle 


Fig.  j2. 


Cephalic  vein 
M.  biceps 


M.  brachialis  anticus 

J Humerus 

.  —I    -     Musculospiral  nerve 

Superior  profunda  artery 
r# Outer  head  of  triceps  muscle 


THE  REGION  OF  THE  ELBOW.  7g 

upon  the  humerus,  it  is  endangered  in  fractures  of  this  bone;  it  is  also  sometimes  included  in  the 
callus  of  a  uniting  fracture  and  causes  corresponding  symptoms.  In  operative  procedures  upon 
the  bone  the  nerve  must  be  carefully  avoided.  Paralysis  of  the  nerve  is  manifested  by  distur- 
bances of  function  of  all  of  the  extensor  muscles  of  the  upper  extremity  (inability  to  extend  the 
hand  and  the  fingers,  wrist-drop)  as  well  as  by  sensory  disturbances  of  the  extensor  surfaces  of 
the  arm,  of  the  forearm,  and  of  the  radial  half  of  the  back  of  the  hand. 

THE  REGION  OF  THE  ELBOW. 

If  the  elbow  is  flexed  in  the  living  subject,  there  may  be  felt  upon  the  flexor  surface  the  strong 
tendon  o]  the  biceps,  from  which  the  sharply  denned  bicipital  fascia  radiates  toward  the  ulnar  side 
(see  Fig.  33).  The  other  landmarks  which  may  be  palpated  are  the  external  and  internal  epicon- 
dyles  and,  running  upward  from  these  points,  the  external  and  internal  condyloid  ridges.  Poste- 
riorly is  the  olecranon,  and,  to  either  side,  the  depressions  which  are  more  or  less  distinctly  marked 
when  the  arm  is  extended.  These  depressions  at  the  margin  of  the  olecranon  mark  the  points 
at  which  the  cavity  of  the  elbow-joint  may  be  most  easily  and  directly  reached  from  behind  (by 
aspiration,  for  example).  In  effusions  into  the  joint  these  depressions  become  less  distinct  or 
even  replaced  by  prominences.  When  the  forearm  is  extended,  the  tip  of  the  olecranon  is  in  a 
line  connecting  the  two  condyles;  when  the  forearm  is  flexed,  the  tip  of  the  olecranon  is  about  one 
centimeter  lower.  It  is  important  to  observe  this  normal  relation,  since  the  tip  of  the  olecranon 
passes  above  this  line  in  backward  dislocations  of  the  ulna  and  in  fractures  of  the  olecranon. 
Between  the  olecranon  and  the  skin  there  is  a  subcutaneous  bursa  (see  Fig.  34)  which  occasionally 
may  lead  to  the  development  of  a  hygroma,  particularly  in  individuals  who  support  themselves  upon 
their  elbows  while  at  work  (miner's  elbow).  Somewhat  higher  up,  within  the  tendon  of  the  triceps 
muscle,  there  is  another  bursa  (bursa  intratendinea  olecrani).  If  the  forearm  is  moved  slightly, 
the  articulation  between  the  external  condyle  and  the  head  of  the  humerus  may  be  felt,  as  may 
also  the  head  of  the  radius,  which  will  be  found  to  rotate  during  the  movements  of  pronation  and 
supination.  To  the  inner  side  of  the  olecranon,  and  running  in  a  groove  upon  the  humerus,  the 
ulnar  nerve  may  be  easily  palpated.  If  it  is  pushed  about  under  firm  pressure  for  a  short  time, 
the  effect  will  be  experienced  in  the  hand.  Upon  the  flexor  surface  the  cutaneous  veins  may  be 
more  or  less  distinctly  seen.  They  are  the  cephalic  vein  upon  the  radial  side,  the  basilic  vein  upon 
the  ulnar  side,  and  the  median  cubital  vein,  the  vein  of  phlebotomy  and  transfusion,  which  runs 
in  an  oblique  direction  from  the  cephalic  up  to  the  basilic  vein.  If  the  median  vein,  running 
upward  upon  the  flexor  surface  of  the  forearm,  divides,  we  speak  of  a  median  cephalic  and  of  a 
median  basilic  vein.  The  transverse  furrow  which  becomes  visible  upon  flexion  of  the  forearm  is 
situated  at  the  level  of  the  epicondyles  and  two  centimeters  higher  than  the  joint. 

Beneath  the  thin  skin  of  the  flexor  surface  and  lying  upon  the  deep  fascia,  which  is  reinforced 
by  the  bicipital  fascia,  are  two  cutaneous  nerves.  Upon  the  ulnar  side  is  the  internal  cutaneous 
nerve,  which  pierces  the  deep  fascia  at  the  hiatus  basilicus  (see  page  78)  and  usually  divides  into 
two  branches.  The  posterior  branch  reaches  the  extensor  surface  at  the  internal  condyle ;  the 
anterior  branch  usually  runs  beneath  the  median  cubital  vein  (or  the  median  basilic  vein)  and 
passes  downward  upon  the  flexor  surface  as  far  as  the  wrist-joint.     The  musculocutaneous  nerve 


80  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

Fig.  33. — The  region  of  the  elbow.     (The  radial  nerve  has  been  drawn  up  from  the  depths  and  made  to  assume  a  more 

superficial  position.) 

pierces  the  deep  fascia  in  the  external  bicipital  groove  to  the  inner  side  of  the  cephalic  vein, 
passes  partly  over  and  partly  under  the  median  cubital  vein  (or  median  cephalic  vein),  and  runs 
downward  to  the  wrist.  At  the  bend  of  the  elbow  there  is  a  constant  and  marked  anastomosis 
between  the  median  cubital  vein  and  the  deep  veins  of  this  region. 

Removing  the  deep  fascia  and  leaving  the  bicipital  fascia  behind,  we  obtain  a  view  of  the 
lower  boundary  of  this  region,  which  is  formed  upon  the  ulnar  side  by  the  edge  of  the  pronator 
radii  teres  muscle,  and  upon  the  radial  side  by  the  inner  border  of  the  supinator  longus  muscle. 
The  brachial  artery  is  easily  exposed.  At  the  lower  end  of  the  internal  bicipital  groove  it  passes 
beneath  the  bicipital  fascia,  lies  to  the  inner  side  of  the  bicipital  tendon,  and  divides  in  front  of  the 
tendon  of  the  brachialis  anticus  into  its  two  terminal  branches,  the  radial  artery  and  the  ulnar 
artery.  The  artery  is  accompanied  by  venae  comites.  In  this  situation  it  is  separated  from  the 
median  cubital  vein  by  nothing  but  the  deep  and  bicipital  fasciae,  and  should  consequently  be 
carefully  avoided  in  phlebotomy  or  transfusion  into  the  vein.  In  the  ligation  of  the  artery  care 
should  also  be  taken  to  avoid  unnecessary  injury  to  the  median  cubital  vein,  which  should  be 
pushed  to  one  side.  If  the  incision  is  made  too  far  to  the  inner  side,  the  median  nerve  will  be 
exposed,  and  the  artery  is  consequently  to  be  sought  for  to  the  outer  side  of  the  wound.  In  this 
region  the  brachial  artery  gives  off  no  special  branches,  but  vessels  are  given  off  almost  immediately 
by  its  two  terminal  divisions.  The  relative  position  of  these  terminal  divisions  is  best  demon- 
strated by  a  sagittal  frozen  section  (see  Fig.  34),  which  shows  that  the  radial  is  at  first  more 
superficial  than  the  ulnar  artery.  In  the  bend  of  the  elbow  the  radial  artery  gives  off  the  radial 
recurrent,  which  ascends  upon  the  supinator  brevis  muscle  toward  the  musculospiral  nerve  to 
supply  the  rete  articulare  cubiti.  The  ulnar  artery  also  assists  in  the  formation  of  this  articular 
anastomosis  by  giving  off  the  anterior  and  posterior  recurrent  branches  which  frequently  arise  by 
a  common  trunk.  The  anterior  ulnar  recurrent  artery  anastomoses  with  the  anastomotica 
magna  from  the  brachial;  the  posterior  ulnar  recurrent  artery  passes  upward  in  the  groove 
between  the  olecranon  and  the  internal  condyle  and  anastomoses  with  the  inferior  profunda  from 
the  brachial. 

A  knowledge  of  the  relations  of  the  three  main  nerves  of  the  arm  is  important  for  all  opera- 
tive procedures  in  the  neighborhood  of  the  elbow-joint.  The  median  nerve,  the  motor  nerve  for 
all  of  the  flexor  muscles  of  the  forearm  (except  the  flexor  carpi  ulnaris  and  the  ulnar  half  of  the 
flexor  profundus  digitorum),  is  situated  beneath  the  bicipital  fascia  to  the  inner  side  of  the  bra- 
chial artery.  This  nerve  reaches  the  forearm  by  piercing  the  pronator  radii  teres,  but  gives  off 
some  muscular  branches  before  entering  this  muscle.  The  ulnar  nerve  is  to  be  found  upon  the 
extensor  surface  alongside  of  the  olecranon  (see  page  78).  In  this  situation  the  ulnar  nerve  is  to 
be  particularly  avoided  in  the  resection  of  the  elbow-joint  from  behind.  The  nerve  passes 
between  the  origins  of  the  flexor  carpi  ulnaris,  coming  from  the  internal  epicondyle  and  from  the 
olecranon,  reaches  the  deep  surface  of  this  muscle,  which  it  supplies,  and  runs  downward  upon 
the  flexor  side  of  the  forearm.  The  musculospiral  nerve  is  quite  deeply  situated  in  the  outer 
portion  of  the  bend  of  the  elbow,  but  may  be  easily  exposed  in  the  groove  between  the  supinator 


Fis-  n 


Inner  head  of  triceps  muscle 

Internal  cutaneous  nerve  ■ 

Internal  intermuscular  septum 

Median  nerve 

Inf.  profunda  and  anastomotica 

magna  arteries.  i>*^ 

Ulnar  nerve  


M.  brachialis  anticus 


Internal  epicondyle 


Ulnar  artery 
Anterior  ulnar  recurrent  artery 


M.  pronator  radii  teres 


THE   FOREARM.  8 1 

longus  and  the  brachialis  anticus  muscles.  After  supplying  the  supinator  longus  and  the  extensor 
carpi  radialis  longior  and  brevior  muscles,  the  nerve  divides  above  the  external  condyle  into  the 
radial  (a  sensory  branch)  and  the  posterior  interosseous  (a  motor  branch  for  the  extensor  muscles 
of  the  forearm). 

The  elbow- joint  is  composed  of  three  articulations: 

i.  The  trochlear  surface  of  the  humerus  with  the  greater  sigmoid  cavity  of  the  ulna. 

2.  The  capitellum  of  the  humerus  with  the  cup-shaped  depression  on  the  head  of  the  radius. 

3.  The  lesser  sigmoid  cavity  of  the  ulna  with  the  circumference  of  the  head  of  the  radius. 

The  first  articulation  is  for  flexion  and  extension,  the  third  is  for  rotation  (pronation  and  supi- 
nation), and  the  second  permits  not  only  of  flexion  and  extension,  but  also  of  rotation.  All  three 
articulations  are  surrounded  by  a  common  lax  capsular  ligament,  which  is  attached  anteriorly 
above  the  coronoid  and  radial  depressions,  excluding  the  epicondyles,  and  posteriorly  above 
the  olecranon  fossa,  which  is  also  situated  within  the  joint.  To  either  side  of  the  olecranon  the 
capsular  ligament  forms  small  diverticula  which  are  situated  beneath  the  cutaneous  depressions 
visible  in  this  situation  in  the  living  subject  (see  page  79).  The  capsular  ligament  is  attached  to 
the  edges  of  the  greater  and  lesser  sigmoid  cavities  of  the  ulna  in  such  a  way  that  the  apex  of  the 
coronoid  process  and  the  olecranon  are  within  the  articular  cavity;  this  ligament  is  also  inserted 
into  the  neck  of  the  radius  so  that  the  head  of  this  bone  is  entirely  within  the  joint. 

The  capsular  ligament  is  reinforced  by  three  other  ligaments: 

1.  The  internal  lateral  ligament,  which  radiates  from  the  internal  epicondyle  to  the  edge  of 
the  greater  sigmoid  cavity  of  the  ulna. 

2.  The  external  lateral  ligament,  which  runs  downward  from  the  external  epicondyle,  some  of 
the  fibers  surrounding  the  neck  of  the  radius  and  being  inserted  into  the  anterior  and  posterior 
margins  of  the  lesser  sigmoid  cavity  of  the  ulna. 

3.  The  orbicular  ligament,  which  enforces  the  capsule  in  a  circular  manner  about  the  neck 
of  the  radius  and  is  inserted  into  the  anterior  and  posterior  margins  of  the  lesser  sigmoid 
cavity  of  the  ulna.  The  external  lateral  and  orbicular  ligaments  form  practically  one  continuous 
band  of  connective  tissue. 

As  the  large  superficial  and  deep  vessels  of  this  region  are  situated  in  front  of  the  elbow-joint, 
it  follows  that  marked  subcutaneous  or  deep  extravasations  of  blood  may  result  from  a  backward 
dislocation  of  both  bones,  and  particularly  from  that  form  which  is  due  to  hyperextension.  In 
this  dislocation  the  median  nerve  is  necessarily  lacerated,  as  it  is  also  in  front  of  the  articulation. 
The  importance  of  the  relation  of  the  ulnar  nerve  to  the  joint  has  been  already  emphasized  (see 
page  80). 

THE  FOREARM. 

The  musculature  of  the  forearm  surrounds  the  radius  and  ulna  and  their  connecting  interos- 
seous membrane  in  such  a  way  that  both  bones  may  be  felt  through  the  skin,  the  ulna  throughout 
its  entire  extent  and  the  radius  in  the  lower  two-thirds  of  the  forearm.  Upon  the  flexor  surface 
in  the  median  line  above  the  wrist  mav  be  seen  more  or  less  distinctly  the  tendon  of  the  palmans 
longus  muscle  (although  it  is  sometimes  absent),  to  the  outer  side  of  which  the  tendon  of  the 

6 


82  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

Fig.  34. — A  longitudinal  section  through  the  region  of  the  elbow  and  the  humero-ulnar  articulation  (frozen  section). 

flexor  carpi  radialis  is  visible.  The  "pulse"  of  the  radial  artery  may  usually  be  felt  just  to  the 
outer  side  of  this  tendon.  The  pulsation  of  the  ulnar  artery  is  scarcely,  if  at  all,  perceptible,  since 
this  vessel  is  covered  by  the  border  of  the  flexor  carpi  ulnaris  muscle  (see  Fig.  35).  The  tendon 
of  this  muscle  may  be  palpated  and  the  incision  for  exposing  the  artery  may  consequently  be 
easily  located. 

Muscles. — The  muscles  of  the  forearm  should  be  reviewed  in  detail  from  a  systematic 
anatomy.  The  flexor  group  may  be  subdivided  into  a  superficial  and  a  deep  layer,  each  consist- 
ing of  four  muscles.  All  of  the  superficial  flexors  originate  from  the  internal  condyle.  The 
pronator  radii  teres  is  inserted  into  the  outer  surface  of  the  middle  of  the  radius.  The  flexor 
carpi  radialis  is  attached  to  the  base  of  the  second  metacarpal  bone.  The  palmaris  longus 
radiates  into  the  palmar  fascia.  The  flexor  carpi  ulnaris,  the  ulnar  origin  of  which  extends 
downward  to  the  lower  third  of  the  bone,  is  inserted  into  the  pisiform  bone,  the  unciform  process 
of  the  unciform  bone,  and  the  base  of  the  fifth  metacarpal  bone. 

There  are  jour  deep  muscles  upon  the  flexor  surface.  The  flexor  sublimis  digitorum  arises 
by  two  heads  from  the  internal  condyle  of  the  humerus  and  from  the  anterior  surface  of  the 
radius  and  is  inserted  by  means  of  four  tendons  into  the  second  phalanges  of  the  fingers.  [This 
muscle  arises  by  three  heads,  one  from  the  inner  condyle  of  the  humerus,  one  from  the  inner 
margin  of  the  coronoid  process  of  the  ulna,  and  one  from  the  radius. — Ed.]  The  flexor 
profundus  digitorum  arises  from  the  upper  two-thirds  of  the  anterior  surface  of  the  ulna  [also 
from  inner  surface. — Ed.]  and  from  the  interosseous  membrane  and  is  inserted  by  means  of  four 
tendons  into  the  terminal  phalanges  of  the  fingers.  The  flexor  longus  pollicis  arises  from  the 
anterior  surface  of  the  radius,  from  the  interosseous  membrane,  and  by  a  small  muscular  slip 
from  the  internal  condyle  and  is  inserted  into  the  terminal  phalanx  of  the  thumb.  The  pronator 
quadratus,  situated  above  the  wrist,  arises  from  the  anterior  surface  of  the  ulna  and  is  inserted 
into  the  anterior  and  outer  surface  of  the  radius. 

The  extensor  muscles  are  subdivided  into  a  radial  group  and  a  dorsal  group. 

The  radial  group  consists  of  four  muscles,  which  arise  from  the  external  condyle  and  from  the 
humerus  above  this  point.  The  supinator  longus  is  inserted  into  the  styloid  process  of  the  radius. 
The  extensor  carpi  radialis  longior  runs  to  the  dorsal  surface  of  the  base  of  the  second  meta- 
carpal bone.  The  extensor  carpi  radialis  brevior  goes  to  the  dorsal  surface  of  the  base  of  the  third 
metacarpal  bone.  The  supinator  brevis,  originating  also  from  a  ridge  upon  the  ulna,  passes  over 
the  radius  and  is  inserted  above  and  below  the  tuberosity  upon  its  anterior  surface. 

The  dorsal  group  of  extensor  muscles,  like  the  flexor  group,  may  be  divided  into  a  super- 
ficial and  a  deep  layer.  The  superficial  layer  consists  of  three  muscles.  The  extensor  carpi 
ulnaris  arises  from  the  external  condyle,  from  the  deep  fascia  of  the  forearm,  and  from  the  posterior 
border  of  the  ulna,  and  is  inserted  into  the  base  of  the  fifth  metacarpal  bone.  The  extensor  com- 
munis digitorum  arises  from  the  external  condyle  and  from  the  deep  fascia  of  the  forearm  and  is 
inserted  by  means  of  four  tendons  into  the  dorsal  aponeuroses  of  the  fingers.  The  extensor 
minimi  digiti  arises  from  the  external  condyle  and  furnishes  a  second  tendon  to  the  little  finger. 

The  deep  layer  of  the  extensor  muscles  arises  from  the  dorsal  surfaces  of  the  ulna,  radius,  and 


Flg-  H- 


Humerus 


M,   triceps .- 


Olecranon   fossa 


Articular  cartilage  ••_-■  £• 


Olecranon 
Subcutaneous  bursa 
over  the  olecranon 


M.  extensor  carpi  ulnaris 


THE   FOREARM.  *  83 

interosseous  membrane.  They  consist  of  four  muscles  which  may  be  subdivided  at  the  middle 
of  the  forearm  into  an  ulnar  and  a  radial  pair  of  muscles.  The  ulnar  pair  is  composed  of  the 
extensor  indicis,  passing  to  the  terminal  phalanx  of  the  index-finger  (both  the  index  and  little 
fingers  consequently  having  two  extensor  tendons),  and  of  the  extensor  longus  pollicis,  which  is 
inserted  into  the  terminal  phalanx  of  the  thumb.  The  radial  pair  is  composed  of  the  extensor 
brevis  pollicis,  which  is  inserted  into  the  base  of  the  first  phalanx  of  the  thumb,  and  of  the  ex- 
tensor ossis  metacarpi  pollicis,  which  is  attached  to  the  base  of  the  metacarpal  bone  of  the  thumb. 
The  muscles  should  also  be  reviewed  in  transverse  section  (see  Fig.  36)  and  the  different  groups  in 
the  illustration  may  be  outlined  by  variously  colored  pencils. 

Arteries. — The  radial  artery,  the  more  superficial  of  the  two  main  arteries  of  the  forearm, 
passes  over  the  tendon  of  the  pronator  radii  teres  muscle  and  is  covered  at  first  by  the  supinator 
longus  muscle.  The  radial  nerve  runs  to  the  radial  side  of  the  radial  artery,  though  at  some- 
distance  from  the  vessel,  and  is  also  covered  by  the  supinator  longus  muscle  (see  page  84).  Above 
the  wrist  the  radial  artery  is  so  superficial  that  in  ligating  the  vessel  it  is  frequently  sought  for  at 
too  great  a  depth.  Below  the  middle  of  the  forearm  the  artery  appears  from  beneath  the  border 
of  the  supinator  longus  and  runs  downward  between  the  tendons  of  the  supinator  longus  and 
flexor  carpi  radialis  muscles.  Just  above  the  wrist  the  vessel  passes  to  the  radial  side  of  the  hand 
(see  Fig.  37).  With  the  exception  of  the  radial  recurrent  (see  page  80),  the  radial  artery  gives  off 
no  large  branches  in  the  forearm. 

The  ulnar  artery  becomes  deeply  situated  immediately  after  its  origin;  it  passes  beneath  the 
pronator  radii  teres  and  runs  upon  the  flexor  profundus  digitorum  in  a  line  corresponding  to  the 
continuation  of  the  brachial.  Above  the  wrist  the  vessel  lies  beneath  the  border  of  the  flexor 
carpi  ulnaris  muscle  and  is  covered  by  two  layers  of  deep  fascia  which  must  be  divided  before 
ligating  the  vessel.  The  ulnar  nerve  is  situated  immediately  to  the  ulnar  side  of  the  vessel.  In 
contrast  with  the  radial  artery,  the  ulnar  always  remains  upon  the  flexor  side  of  the  forearm  and 
passes  into  the  hand  at  the  radial  side  of  the  pisiform  bone,  where  it  may  also  be  exposed  and 
li gated  with  comparative  ease.  The  main  branch  is  the  common  interosseous  artery,  which  divides 
immediately  after  its  origin  into  the  anterior  and  posterior  interosseous.  The  anterior  interosse- 
ous artery  runs  downward  upon  the  anterior  surface  of  the  interosseous  membrane  to  the  upper 
margin  of  the  pronator  quadratus,  where  it  passes  to  the  dorsal  surface  to  the  arterial  anastomosis 
at  the  back  of  the  wrist  (rete  carpi  dorsale).  The  posterior  interosseous  artery  passes  through 
the  interosseous  membrane  to  the  extensor  surface,  is  smaller  than  the  anterior  interosseous,  and 
also  ends  in  the  rete  carpi  dorsalis. 

Nerves.— The  relations  of  the  three  great  nerves  of  the  arm  in  this  situation  must  also  be 
considered.  The  median  nerve  perforates  the  pronator  radii  teres,  runs  between  the  flexor  sub- 
lines and  flexor  profundus  digitorum,  supplying  the  neighboring  muscles,  and  escapes  from 
beneath  the  flexor  sublimis  digitorum  above  the  wrist  (see  Fig.  35),  where  it  may  easily  be  ex- 
posed, to  the  radial  side  of  the  tendon  of  the  palmaris  longus  [or  is  found  directly  beneath  this 
tendon.— Ed.].  In  this  situation  the  nerve  is  occasionally  injured  in  suicidal  attempts,  in  wounds  of 
the  vessels,  or  bv  sabre-cuts.  Such  injuries  are  followed  by  paralysis  of  the  opponens  pollicis  muscle 
and  by  a  loss  of  sensation  upon  the  radial  side  of  the  palm  (see  page  87).  The  branch  supplying 
the  deep  flexors  ends  in  the  anterior  interosseous  nerve,  which  runs  upon  the  interosseous  mem- 


84  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

Fig.  35. — The  anterior  aspect  of  the  forearm  above  the  wrist.  The  ulnar  artery  and  nerve  have  been  made 
visible  by  displacing  the  tendon  of  the  flexor  carpi  ulnaris. 

Fig.  36. — A  cross-section  through  the  middle  of  the  forearm. 

brane  with  the  anterior  interosseous  artery  to  the  pronator  quadratus  muscle.  A  small  palmar 
branch  passes  alongside  of  the  tendon  of  the  flexor  carpi  radialis  to  the  skin  of  the  palm.  Par- 
alysis of  the  median  nerve  is  followed  by  a  loss  of  radial  flexion  (flexor  carpi  radialis)  and  of 
flexion  of  the  fingers  (flexor  sublimis  and  profundus  digitorum);  the  thumb  is  extended  and 
adducted  (the  adductor  pollicis  is  supplied  by  the  ulnar  nerve).  The  ulnar  nerve,  after  reaching 
the  deep  surface  of  the  flexor  carpi  ulnaris,  gradually  approaches  the  ulnar  artery  and  comes  in 
relation  with  its  ulnar  side  at  about  the  middle  of  the  forearm.  It  lies  between  the  flexor  pro- 
fundus digitorum  and  the  flexor  carpi  ulnaris  and;  below  the  middle  of  the  forearm,  divides  into 
a  large  anterior  branch,  which  follows  the  ulnar  artery  (see  page  83),  and  a  smaller  posterior 
branch,  which  reaches  the  back  of  the  hand  by  passing  beneath  the  flexor  carpi  ulnaris.  Paralysis 
of  the  ulnar  nerve  is  followed  by  a  loss  of  ulnar  flexion  of  the  hand  (flexor  carpi  ulnaris)  and 
by  an  impairment  of  motion  of  the  terminal  phalanges  of  the  fingers  upon  the  ulnar  side  (flexor 
profundus  digitorum).  The  musculospiral  nerve,  while  still  in  the  region  of  the  bend  of  the 
elbow,  divides  into  the  motor  posterior  interosseous  nerve  and  the  sensory  radial  nerve.  The 
posterior  interosseous  nerve  pierces  the  supinator  brevis,  and  at  the  lower  border  of  this  muscle 
(upon  the  extensor  side  of  the  forearm)  gives  off  numerous  branches  which  ramify  between  the 
superficial  and  deep  groups  of  muscles  and  supply  all  of  the  extensors  in  the  forearm.  The 
radial  group  of  muscles  is  supplied  by  the  nerve  before  its  entrance  into  the  supinator  brevis. 
The  continuation  of  the  nerve  runs  upon  the  interosseous  membrane  as  a  small  branch  which 
reaches  the  back  of  the  wrist.  The  radial  nerve  is  at  first  covered  by  the  supinator  longus; 
about  a  handbreadth  above  the  wrist  it  passes  beneath  the  tendon  of  the  supinator  longus  to  the 
extensor  side  and  to  the  dorsal  surface  of  the  hand.  If  the  musculospiral  nerve  is  injured  (for 
example,  by  an  injury  of  the  soft  parts  of  the  upper  arm  or  by  a  fracture  of  the  humerus),  there  is, 
in  addition  to  the  loss  of  motion  of  the  extensors  and  of  the  muscles  of  the  radial  group,  a  loss  of 
sensation  upon  the  extensor  surfaces  of  the  upper  arm,  of  the  forearm,  and  of  the  radial  half  of 
the  back  of  the  hand  (see  page  78). 

THE  HAND. 

The  dividing-line  between  the  forearm  and  the  hand  is  easily  determined  in  the  living  subject 
by  locating  the  styloid  processes  of  the  radius  and  ulna.  The  line  connecting  these  two  processes 
corresponds  to  the  wrist-joint,  and  if  it  is  desired  to  disarticulate  the  hand  or  excise  the  wrist- 
joint,  the  knife  must  be  introduced  immediately  to  the  distal  side  of  these  processes. 

Upon  the  palmar  surface  of  the  base  of  the  hand  may  be  seen  and  felt  the  hand  prominences 
produced  by  the  eminentia  carpi  radialis  and  ulnaris.  The  eminentia  carpi  radialis  is  formed 
by  the  tubercle  of  the  scaphoid  and  by  the  ridge  of  the  trapezium;  the  eminentia  carpi  ulnaris  is 
formed  by  the  pisiform  bone  and  by  the  unciform  process  of  the  unciform  bone.  These  eminences 
are  united  by  the  anterior  annular  ligament  which  converts  the  deep  groove  lying  between  them 
into  the  important  carpal  canal.     When  the  thumb  is  abducted,  a  marked  prominence  appears 


Kg-  iS 


M.  flexor  carpi  ulnaris 


M.  flexor  digitorum  sublim 
M    palmaris  longus 

Median  nerve 

Palmar  cutaneous  branch 

of  median  nerve 
M.   flexor  carpi  radialis 

Radial  artery 

Radial  nerve 


Fig.  j6. 


M.   flexor  carpi  radialis   . 


Median  nerve 
Radial  artery 
M.  supinator  longus 
Cephalic  vein 
Radial  nerve 
M.   flexor  pollicis  longus 

M.  ext.  carpi  rad.  long. 
Radius 

M.  Extensor  carpi 
radialis  brevis 
M.  abductor  poll.  long,  et 
m.  extens.  poll,  brevis 


M.  extensor  digitorum 
communis 


M    palmaris  longus 


M.  flexor  digitorum 

sublimis 
Ulnar  artery 
Ulnar  nerve 
M.  flexor  carpi  ulnaris 

M.   flexoi   digitoium 
profundus 

Anterior  interosseous  nerve 
Anterior  interosseous  artery 

Ulna 

Posterior  interosseous  artery 

M.  extensor  longus_  pollicis 
and  m.  extensor  indicis 

M.  extensor  carpi   ulnaris 


THE   HAND.  o 

85 

upon  the  radial  border  of  the  base  of  the  hand,  which  is  produced  by  the  tendons  of  the  extensor 
ossss  metacarpus  and  extensor  brevis  pollicis  muscles.  Two  centimeters ^rio  "the  I 
tendons  may  be  easily  seen  and  felt  the  tendon  of  the  extensor  longus  pollicis  Z  its  way  to  th 
u  u'u  JheSe.Prommences  ^e  separated  by  a  fossa,  the  so-called  tabatiere  or  "snuff-box" 
winch  holds  an  important  relation  to  the  course  of  the  radial  artery  (see  page  86).  Upon  the 
dorsal  surface  of  the  hand  may  also  be  noted  the  network  of  subcutaneous  veins  and  the  extensor 
tendons  which  become  more  prominent  when  the  fingers  are  moved.  As  the  extensor  tendons 
approach  the  wrist  they  disappear  from  view,  since  they  enter  their  sheaths  in  this  situation 

Upon  the  dorsal  aspect  of  the  hand  the  metacarpal  bones  and  the  phalanges  may  be  easily 
palpated,  while  the  palmar  surface  of  these  structures  is  well  covered  by  the  soft  parts     If  the 
dorsal  surface  of  the  base  of  a  slightly  flexed  finger  is  palpated  by  the  thumb  and  index-finger  of 
the  other  hand,  the  metacarpophalangeal  joint  and  the  thick  base  of  the  first  phalanx  may  be 
easily  recognized.     In  the  closed  fist  the  line  of  this  metacarpophalangeal  joint  js  one  centimeter 
below  (t.  e.,  towards  the  nail)  the  most  prominent  portion  of  the  knuckle,  and  the  same  statement 
holds  for  all  of  the  interphalangeal  joints.     This  is  something  that  must  be  felt,  if  disarticulations 
are  to  be  performed  at  these  joints  lege  artis.     If  the  hand  is  not  too  fat,  the  joint  between  the 
trapezium  and  the  first  metacarpal  bone  (saddle-joint)  may  be  palpated  at  the  base  of  the  thenar 
eminence  by  following  the  course  of  the  metacarpal  bone  with  the  finger.     If  the  hand  is  laid 
palm  downward  upon  a  table  and  the  finger  is  passed  backward  in  the  groove  between  the  second 
and  third  metacarpal  bones,  it  reaches  the  " dorse-radial"  fossa  (Rotter),  which  is  filled  out 
during  dorsal  flexion  of  the  hand  by  the  tendons  of  the  extensor  carpi  radialis  longior  and  brevior. 
The  location  of  this  fossa  is  important  for  operative  procedures  (dorso-radial  incision  of  Langen- 
beck  for  resection  of  the  wrist- joint). 

The  palmar  jascia  radiates  from  the  tendon  of  the  palmaris  longus  and  is  situated  beneath 
the  subcutaneous  fat  of  the  palm.  It  is  the  fascia  which  is  responsible  for  Dupuytren's  finger 
contraction.  Together  with  the  tough  skin  of  the  palm,  it  forms  a  dense  layer  of  tissue  which  resists 
the  spontaneous  perforation  of  inflammatory  processes  deeply  situated  in  the  palm.  It  divides 
into  five  slips  which  are  adherent  to  the  skin  at  the  bases  of  the  fingers  and  of  the  thumb;  in 
hands  which  are  not  too  lean,  the  skin  of  the  interdigital  folds  forms  small  elevations  which  are 
due  to  the  projection  of  the  subcutaneous  fat  between  these  slips.  The  transverse  ligament  runs 
between  and  connects  the  slips  passing  to  the  four  fingers.  The  fascia  is  considerably  thinner 
over  the  thenar  and  hvpothenar  eminences. 

The  deep  fascia  of  the  forearm  is  reinforced  over  the  wrist-joint  by  transverse  fibers  which 
form  the  anterior  and  posterior  annular  ligaments.  The  latter  is  of  interest  to  the  practitioner  on 
account  of  its  relation  to  the  extensor  tendons.  The  posterior  annular  ligament  passes  trans- 
versely from  the  styloid  process  of  the  radius  to  the  styloid  process  of  the  ulna  and  forms  six  com- 
partments for  the  tendons  by  giving  off  septa  to  the  radius  and  ulna.  These  compartments  or 
tendon-sheaths,  though  much  less  frequently  affected  than  the  palmar  compartment  (see  page 
87),  are  occasionally  the  seat  of  tendovaginitis.  Passing  from  the  radial  to  the  ulnar  side  the 
compartments  are  as  follows:  (1)  For  the  tendons  of  the  extensor  ossis  metacarpi  pollicis  and  of 
the  extensor  brevis  pollicis;  (2)  for  the  tendons  of  the  extensor  carpi  radialis  longior  and  brevior; 
(3)  for  the  tendon  of  the  extensor  longus  pollicis;    (4)  for  the  tendons  of  the  extensor  communis 


86  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  37. — The  muscles,  nerves,  vessels,  and  tendon-sheaths  of  the  palm  of  the  hand.  The  tendon-sheaths  are 
colored  blue.     The  carpal  canal  has  been  opened  by  dividing  the  anterior  annular  ligament. 

Fig.  38. — Diagrammatic  representation  of  the  joints  of  the  hand. 

digitorum  and  of  the  extensor  indicis;  (5)  for  the  tendon  of  the  extensor  minimi  digiti;  and  (6) 
for  the  tendon  of  the  extensor  carpi  ulnaris.  The  second  and  third  compartments  are  frequently 
combined  to  form  a  single  sheath. 

The  anterior  annular  ligament  connects  the  eminentia  carpi  radialis  with  the  eminentia 
carpi  ulnaris  and  forms  the  roof  of  the  carpal  canal.  This  canal  transmits  the  flexor  tendons  of  the 
fingers  (flexor  sublimis  and  profundus  digitorum  and  flexor  longus  pollicis)  and  the  median  nerve, 
which  pass  into  the  palm  of  the  hand.  The  median  nerve  lies  upon  the  tendons  immediately 
beneath  the  ligament.  The  ulnar  nerve  and  artery,  however,  pass  into  the  hand  over  the  anterior 
annular  ligament  to  the  radial  side  of  the  pisiform  bone.  At  the  lower  end  of  the  radius,  distal 
to  the  insertion  of  the  supinator  longus,  the  radial  artery  passes  from  the  flexor  to  the  extensor 
side,  between  the  styloid  process  of  the  radius  and  the  scaphoid  bone.  It  passes  beneath  the 
tendons  of  the  extensor  ossis  metacarpi  pollicis  and  extensor  brevis  pollicis  into  the  tabatiere  or 
"snuff-box"  (see  page  85),  and  then  runs  beneath  the  tendon  of  the  extensor  longus  pollicis  to 
reach  the  space  between  the  first  two  metacarpal  bones.  The  vessel  then  leaves  the  back  of  the 
hand  and  passes  into  the  palm  between  the  heads  of  the  first  dorsal  interosseous  muscle.  During 
this  course  the  radial  artery,  in  addition  to  branches  to  the  rete  carpi  dorsale  and  volare  [that  is, 
the  vascular  network  on  the  dorsal  and  palmar  surfaces  of  the  wrist. — Ed.],  gives  off  two 
vessels  which  vary  considerably  in  size : 

1 .  The  super ficialis  voice,  which  is  often  absent,  though  frequently  as  large  as  the  continuation 
of  the  radial.  It  leaves  the  radial  at  the  styloid  process  of  the  radius  and  passes  over  the  origins 
of  the  short  muscles  of  the  thumb  to  unite  with  the  ulnar  artery  and  form  the  superficial  palmar 
arch.  This  branch  is  covered  only  by  the  skin  and  a  thin  fascia  (and  sometimes  also  by  a  few 
slips  from  the  muscles  of  the  thumb),  and,  when  well  developed,  is  a  dangerous  vessel  on  account 
of  its  exposed  position.     In  some  individuals  its  pulsations  may  be  seen  through  the  skin. 

2.  The  prince ps  pollicis,  which  passes  between  the  muscles  of  the  ball  of  the  thumb  to  the 
palmar  surface  and  gives  off  three  digital  branches  to  supply  both  sides  of  the  thumb  and  the 
radial  side  of  the  index-finger. 

The  terminal  portion  of  the  radial  artery  anastomoses  with  the  deep  branch  of  the  ulnar  and 
forms  the  deep  palmar  arch,  which  is  situated  upon  the  bases  of  the  metacarpal  bones.  This  arch 
gives  off  the  palmar  interosseous  arteries,  which  are  usually  small  in  size  and  pass  distally  between 
the  bases  of  the  first  phalanges  to  empty  into  the  digital  branches  of  the  superficial  arch.  If  the 
superficial  arch  and  some  or  all  of  its  digital  branches  are  poorly  developed,  the  palmar  inter- 
osseous arteries  are  larger  and  furnish  the  digital  arteries  for  the  fingers. 

The  ulnar  artery,  in  contrast  to  the  radial,  always  remains  upon  the  flexor  side  of  the  forearm. 
After  giving  off  the  anterior  and  posterior  carpal  branches,  it  passes  over  the  anterior  annular 
ligament  to  the  radial  side  of  the  pisiform  bone.  In  the  palm  of  the  hand  it  gives  off  a  deep 
branch  and  then  unites  with  the  superficialis  volae  from  the  radial  to  form  the  superficial  palmar 
arch,  which  is  situated  immediately  beneath  the  palmar  fascia.     From  the  superficial  palmar  arch 


Ulnar  nerve 

Ulnar  artery- 
Sheath  of  the  flexor  tendons 

Median  nerve 

Superficial  palmar  branch 

Deep  palmar  branch 

Deep  branch  of  ulnar  artery 

M.  abductor  minimi  digiti 

M.  flexor  brevis  minimi  digiti 

M.   opponens  minimi  digiti 


M.  flexor  carpi  radi^lis 
M.  flexor  pollicis  longus 


Digital  branches  of  the 
superficial  palmar  arch 


Digital  arteries 
Digital  nerves 


Radius 

Radio-carpal  articulation 
Semilunar  bone 

Scaphoid  bone 

Intercarpal,  carpometacarpal,  and 

intermetacarpal  articulations  ^  A 

Trapezium  —     ---,4n 
Trapezoid  bone 
Carpometacarpal  articulation 
of  the  thumb 
First  metacarpal  bone 

— £^ 


F'g-  n- 


~.-r.-..     Radial  artery 

;;*Sheath  of  tendon  of  the  flexor  carpi  radialis  muscle 

M.  extensor  ossis  metacarpi  pollicis 
"""  Superficialis  volae  artery 

Anterior  annular  liga- 
ment (divided) 

M.  opponens  pollicis 
M.  abductor  pollicis 

M.  flexor  pollicis 
brevis 

M.  adductor  pollicis 
Sheath  of  tendon  of  m. 
flexor  longus  pollicis 


---  —  Lumbrical  muscles 


Sheaths  of  the    flexor 
tendons 


...  Ulna  Fi&  J8- 

—  Inferior  radio-ulnar  articulation 

—  Interarticular  cartilage 
...  Cuneiform  bone 

-—Pisiform  bone 

—  Articulation  of  pisiform  bone 

Os  magnum 

—  Unciform  bone 
._.  Fourth  and  fifth  metacarpal 

articulation 

Fifth  metacarpal  bone 


THE   HAND.  87 

arise  all  of  the  digital  branches  for  the  fingers,  with  the  exception  of  the  three  furnished  by  the 
arteria  princeps  pollicis.  The  convexity  of  the  superficial  palmar  arch  barely  reaches  to  the 
middle  one  of  the  three  lines  which  diverge  from  the  base  of  the  index-finger  to  the  ulnar  border 
of  the  hand. 

The  median  nerve  lies  upon  the  common  sheath  of  the  flexor  tendons  and  passes  through 
the  carpal  canal  in  company  with  these  structures  (see  page  86).  It  gives  off  seven  digital  branches 
which  supply  the  palmar  surfaces  of  the  thumb,  index,  middle  and  radial  side  of  the  ring  fingers 
and  inosculate  with  the  digital  branches  of  the  ulnar  nerve.  With  the  exception  of  the  adductor 
pollicis,  the  muscles  of  the  thumb  are  also  supplied  by  the  median  nerve. 

The  ulnar  nerve  is  situated  to  the  inner  side  of  the  ulnar  artery,  passes  into  the  hand  to  the 
radial  side  of  the  pisiform  bone,  and  immediately  divides  into  a  superficial  palmar  branch,  for  the 
ulnar  side  of  the  ring  finger  and  for  both  sides  of  the  little  finger,  and  a  deep  palmar  branch,  which 
follows  the  deep  branch  of  the  ulnar  artery  and  accompanies  the  deep  palmar  arch,  supplying  the 
muscles  of  the  hypothenar  eminence,  all  of  the  interosseous  muscles,  and  ending  in  the  adductor 
pollicis  muscle.  There  are  no  motor  nerves  upon  the  dorsal  surface  of  the  hand.  The  dorsal 
cutaneous  branch  of  the  ulnar  ends  in  sensory  filaments  which  supply  the  ulnar  half  of  the  back 
of  the  hand.  In  this  situation  these  filaments  inosculate  with  the  radial  nerve,  which  furnishes 
sensory  branches  for  the  radial  half  of  the  back  of  the  hand  (see  page  84). 

In  the  palm  of  the  hand  there  are  three  synovial  sheaths  for  the  tendons,  in  addition  to  a 
small  unimportant  one  for  the  terminal  portion  of  the  tendon  of  the  flexor  carpi  radialis: 

1.  The  common  large  synovial  sheath  for  the  tendons  of  the  flexor  sublimis  and  profundus 
digitorum.  This  extends  about  two  centimeters  above  the  anterior  annular  ligament  (toward  the 
forearm);  exudates  to  the  proximal  side  of  the  ligament  may  consequently  make  themselves 
manifest  by  the  presence  of  a  superficial  swelling. 

2.  The  synovial  sheath  for  the  tendon  of  the  flexor  longus  pollicis.  This  also  commences 
to  the  proximal  side  of  the  anterior  annular  ligament  and  envelops  the  tendon  almost  to  the  very 
point  of  its  insertion  into  the  terminal  phalanx  of  the  thumb.  It  frequently  communicates  with 
the  common  synovial  sheath  of  the  flexor  tendons  of  the  fingers  beneath  the  anterior  annular 
ligament. 

3.  The  individual  tendon-sheaths  of  the  index,  middle,  ring,  and  little  fingers,  each  one  of 
which  envelops  one  of  the  superficial  and  one  of  the  deep  flexor  tendons.  As  a  rule,  the  tendon- 
sheath  of  the  little  finger  is  directly  continuous  proximally  with  the  common  sheath  of  the  flexor 
tendons  of  the  fingers. 

It  follows  that  tenosynovitis,  resulting  from  injuries  or  inflammations  of  the  fingers,  finds  a 
favorable  path  for  its  extension  toward  the  forearm,  particularly  when  situated  in  the  thumb 
and  little  finger.  As  the  tendon-sheaths  of  the  little  finger  and  of  the  thumb  are  continuous  with 
the  common  synovial  sheath  at  the  wrist  *  we  can  readily  understand  the  occurrence  of  those  cases 
in  which  an  inflammation  extends  through  the  palm  from  the  thumb  to  the  little  finger,  or  in  the 
reverse  direction.  Clinical  observations  show  that  the  individual  tendon-sheaths  of  the  index, 
middle,  and  ring  fingers  are  occasionally  also  continuous  with  the  common  synovial  sheath. 

As  there  are  no  tendon-sheaths  upon  the  backs  of  the  fingers,  and  since  the  sheaths  of  the 

*  The  sheath  for  the  thumb  is  less  frequently  continuous  than  is  that  for  the  little  finger.— Ed. 


88  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

extensor  tendons  are  not  continued  into  the  fingers,  tenosynovitis  occurs  much  more  rarely  upon 
the  dorsal  than  upon  the  palmar  surface. 

The  following  articulations  may  be  differentiated  at  the  wrist: 

i.  The  radiocarpal  articulation  or  wrist- joint,  between  the  radius  and  the  distal  surface  of 
the  interarticular  fibrocartilage  on  one  side,  and  the  scaphoid,  semilunar,  and  cuneiform  bones 
upon  the  other. 

2.  The  inferior  radio-ulnar  articulation  between  the  sigmoid  cavity  of  the  radius  and  the  head 
of  the  ulna.     This  joint  is  completely  separated  from  the  preceding  one. 

3.  (a)  The  intercarpal  articulations,  between  the  carpal  bones;  (b)  the  carpometacarpal 
articulations,  between  the  second  row  of  the  carpal  bones  and  the  metacarpal  bones;  (c)  the 
intermetacarpal  articulations,  between  the  lateral  articular  surfaces  of  the  bases  of  the  metacarpal 
bones.  These  three  sets  of  articulations  usually  possess  a  common  synovial  membrane;  the 
carpal  bones  are  joined  together  by  the  tense  interosseous  ligaments.  The  synovial  cavity  of  the 
joint  between  the  unciform  and  the  fourth  and  fifth  metacarpal  bones  is  occasionally  separated 
from  the  large  synovial  cavity  of  the  carpus. 

4.  The  articulation  between  the  pisiform  and  the  cuneiform  bones. 

5.  The  articulation  of  the  metacarpal  bone  of  the  thumb  with  the  trapezium  (saddle-joint). 
In  disarticulating  at  this  joint  care  must  be  taken  to  avoid  injuring  the  articulation  between  the 
trapezium  and  the  second  metacarpal  bone,  as  such  an  injury  would  open  up  the  common  synovial 
cavity  of  the  carpus. 

The  following  ligaments  should  be  noted : 

1.  The  external  lateral  ligament,  from  the  styloid  process  of  the  radius  to  the  scaphoid  bone. 

2.  The  internal  lateral  ligament,  from  the  styloid  process  of  the  ulna  to  the  cuneiform  bone. 

3.  The  anterior  ligament,  in  front  of  the  wrist-joint,  from  the  lower  end  of  the  radius  to  the 
scaphoid,  semilunar,  and  cuneiform  bones  and  to  the  os  magnum. 

4.  The  posterior  ligament,  behind  the  wrist-joint,  from  the  lower  end  of  the  radius  to  the 
scaphoid,  semilunar,  and  cuneiform  bones. 

5.  The  ligamentum  carpi  radiatum,  on  the  anterior  surface  of  the  carpus,  which  connects 
the  os  magnum  with  the  surrounding  bones. 

A  transverse  section  of  the  finger  recalls  the  fact  that  the  tendons  of  the  superficial  and  deep 
flexors  run  in  a  common  sheath  upon  the  palmar  surface,  and  that  there  is  no  such  sheath  upon 
the  dorsal  surface.  Upon  the  back  of  the  finger  the  extensor  tendon  becomes  continuous  with 
the  dorsal  aponeurosis.  The  larger  vessels  and  nerves  are  situated  upon  the  palmar  surface, 
while  the  smaller  ones  are  upon  the  dorsal  surface.  The  nerves  of  the  palmar  surface  are  nearer 
the  median  line  of  the  finger  than  the  digital  arteries,  which  anastomose  freely  at  the  pulp  of  the 
finger.  The  palmar  nerves  of  the  fingers  also  supply  the  dorsal  surfaces  of  the  terminal  phalanges, 
which  are  not  reached  by  the  small  dorsal  nerves. 

QUESTIONS. 

Beneath  what  portion  of  the  clavicle  does  the  subclavian  artery  pass  ? 

What  important  structures  may  be  compressed  in  a  fracture  of  the  clavicle  or  of  the  neck  of  the 
humerus  or  by  a  subcoracoid  dislocation  of  the  shoulder? 


THE   THORACIC   WALL.  g 

In  what  cases  are  the  lymphatic  glands  of  the  axilla  of  particular  interest  to  the  surgeon  and  why? 
U  hat  muscle  aids  in  the  location  of  the  axillary  artery  ? 

arteriel^1  ^  ^  "^  imP°rtant  anastomosis  ***™*  the  branches  of  the  axillary  and  subclavian 

What  nerves  are  endangered  in  cleaning  out  the  axillary  cavity  (in  mammary  carcinoma)? 

\\  hat  two  bursas  communicate  with  the  shoulder-joint  ? 

Where  are  the  two  weak  places  in  the  capsular  ligament  of  the  shoulder-joint  ? 

What  bursa,  when  diseased,  may  be  confused  with  an  exudate  in  the  shoulder-joint? 

Where  may  the  pulsations  of  the  brachial  artery  be  felt  ? 

What  nerve  of  the  upper  arm  is  involved  first  in  affections  of  the  humerus  (by  a  fracture 
for  example)  ? 

In  what  situations  may  the  elbow-joint  be  most  easily  opened  ? 
What  is  the  normal  relation  of  the  olecranon  to  the  epicondyles  of  the  humerus? 
Where  may  the  ulnar  nerve  be  palpated  about  the  elbow  ? 
What  nerve  is  to  be  particularly  avoided  in  resection  of  the  elbow-joint  ? 

What  effect  must  hyperextension  of  the  elbow  with  backward  dislocation  of  both  bones  have  upon 
the  large  vessels  and  nerves? 

Between  what  tendons  may  the  radial  pulse  be  felt  at  the  wrist,  and  why  is  the  pulsation  of  the  ulnar 
artery  scarcely,  if  at  all,  perceptible  in  this  situation  ? 

What  symptoms  are  characteristic  of  paralysis  of  the  musculospiral,  median,  and  ulnar  nerves, 
and  how  are  these  symptoms  explained  by  the  distribution  of  the  nerves? 

Why  do  inflammations  of  the  tendon-sheaths  of  certain  fingers  (which  ones?)  extend  into  the  fore- 
arm more  readily  than  similar  inflammations  in  other  fingers? 

Why  is  tenosynovitis  more  common  upon  the  palmar  than  upon  the  dorsal  surface  ? 


THE  THORAX. 

THE  THORACIC  WALL. 

The  external  boundaries  of  the  thorax  are  easily  defined  in  the  living  subject. 

The  upper  boundary  of  the  thorax  is  formed  anteriorly  in  the  median  line  by  the  upper 
margin  of  the  sternum,  laterally  by  the  clavicles,  and  posteriorly  by  lines  drawn  from  the 
acromion  processes  to  the  spinous  process  of  the  seventh  cervical  vertebra  (vertebra  prominens). 

The  lower  boundary  of  the  thorax  is  formed  anteriorly  in  the  median  line  by  the  xiphoid 
process  of  the  sternum,  laterally  by  the  costal  margins,  and  posteriorly  by  lines  drawn  from  the 
lowest  point  of  the  costal  margins  (near  the  axillary  lines)  to  the  spinous  process  of  the  eleventh 
dorsal  vertebra. 

The  internal  boundaries  of  the  thorax,  i.  e.,  the  planes  separating  the  thoracic  space*  from 

*The  space  surrounded  by  the  thoracic  wall  and  situated  above  the  diaphragm  is  improperly  designated  as  the 
"thoracic  cavity."  As  a  thoracic  cavity  (like  an  abdominal  cavity)  does  not  exist,  it  would  be  better  to  avoid  this  ex- 
pression altogether.  The  space  surrounded  by  the  thoracic  wall — the  thoracic  space — contains  three  cavities:  two  pleural 
cavities  and  a  pericardial  cavity.  The  surgeon,  and  sometimes  the  anatomist,  frequently  speaks  of  an  opening  into  the 
thoracic  cavity  (from  an  injury,  for  example),  by  which  is  meant  an  opening  into  the  pleural  and  pericardial  cavities 
or  into  one  of  these  three  cavities. 


90  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

the  contents  of  the  neck  and  abdomen,  do  not  correspond  with  the  external  boundaries;  they 
are  more  difficult  to  determine  in  the  living  subject. 

The  upper  boundary  of  the  thoracic  space  in  the  erect  position  and  during  expiration  lies 
in  a  horizontal  plane  which  passes  through  a  point  four  centimeters  above  the  middle  of  the 
upper  margin  of  the  sternum.  This  plane  passes  through  the  intervertebral  disc  between  the 
last  cervical  and  the  first  dorsal  vertebra.  It  is  about  two  centimeters  above  the  center  of  the 
clavicle,  so  that  the  physician  may  examine  a  portion  of  the  thoracic  contents  above  this  bone. 

The  lower  boundary  of  the  thoracic  space  is  formed  by  the  diaphragm,  the  arched  dome 
of  which,  during  expiration,  is  at  the  level  of  the  fourth  intercostal  space  in  the  right  mammary 
line  and  a  fingerbreadth  lower  in  the  left  mammary  line  at  the  upper  margin  of  the  fifth  rib. 

The  physician,  as  well  as  the  anatomist,  needs  certain  definite  vertical  and  horizontal  lines 
for  the  purpose  of  defining  the  positions  of  the  organs  of  the  thoracic  cavity  in  health  and  in 
disease. 

The  vertical  lines  are :  The  mammary  line,  passing  through  the  nipple  [the  position  of  the 
nipple  is  so  variable  that  the  mammary  line  should  be  abandoned  in  favor  of  the  mid-clavicular 
line;  the  latter  starts  from  a  fixed  and  easily  determined  point,  passes  usually  slightly  internal 
to  the  nipple,  and  in  normal  subjects  is  continuous  with  the  Poupart  perpendicular  drawn  from 
the  mid-point  between  the  symphysis  pubis  and  the  anterior  superior  spinous  process  and  used 
by  many  writers  in  delimiting  the  abdominal  regions. — Ed.]  ;  the  sternal  line,  along  the  margin  of 
the  sternum ;  the  parasternal  line,  midway  between  the  mammary  and  sternal  lines ;  and  the  axillary 
line,  which  passes  downward  from  the  highest  point  of  the  axillary  fossa  (also  known  as  the  middle 
axillary  line).  The  anterior  axillary  line  passes  vertically  downward  from  the  point  at  which 
there  appears  the  prominence  caused  by  the  lower  margin  of  the  pectoralis  major  as  it  leaves 
the  thoracic  wall;  the  posterior  axillary  line  extends  vertically  downward  from  the  correspond- 
ing point  of  the  latissimus  dorsi.  The  costoclavicular  line  is  drawn  from  the  sternoclavicular 
articulation  to  the  end  of  the  eleventh  rib  and  is  employed  to  determine  the  normal  position  of 
the  spleen.  The  scapular  line  passes  through  the  inferior  angle  of  the  scapula.  These  lines 
are  supplemented  by  the  anterior  and  posterior  median  lines. 

The  horizontal  lines  are  furnished  by  the  intercostal  spaces.  At  the  upper  portion  of  the 
sternum,  the  sternal  angle  (angle  of  Ludwig)  may  be  seen  and  felt  as  a  transverse  elevation.  It 
corresponds  to  the  synchondrosis  between  the  manubrium  and  the  gladiolus  and  to  the  attach- 
ment of  the  second  costal  cartilage.  In  this  manner  the  second  intercostal  space  may  be  easily 
located  and  the  remaining  intercostal  spaces  may  be  defined  by  firm  palpation  from  above  down- 
ward and  backward.  The  importance  of  these  localizing  lines  is  clear;  for  example,  the  apex 
of  the  normal  heart  (apex-beat)  is  situated  in  the  fifth  intercostal  space  between  the  mammary 
and  the  parasternal  lines.  The  third  intercostal  space  is  the  broadest,  then  follow  the  first  and 
the  second;  all  of  the  other  intercostal  spaces  are  narrower,  the  last  one  being  the  narrowest. 
The  intercostal  spaces  are  broader  anteriorly  than  posteriorly,  for  which  reason  penetrating 
injuries  from  behind  (a  gunshot  wound,  for  example)  are  more  frequently  complicated  with 
injuries  to  the  ribs  than  are  similar  wounds  from  in  front. 

[Anteriorly  the  thorax  is  divided  into  the  following  regions:  Supraclavicular,  that  portion 
above  the  clavicle;   infraclavicular,  between  the  clavicle  and  the  third  rib;  mammary,  between 


THE   THORACIC  WALL.  gi 

the  third  and  sixth  ribs;  and  inframammary,  below  the  sixth  rib.  Laterally  the  sixth  rib  divides 
the  area  into  two  regions,  axillary  above  and  infraaxillary  below.  Posteriorly  the  space  above 
the  spine  of  the  scapula  is  known  as  the  suprascapular;  that  below  as  the  inf rascapular ;  that 
between  the  vertebral  borders  of  the  scapula  as  the  interscapular. — Ed.] 

Supernumerary  ribs  occasionally  occur.  The  supernumerary  rib  proceeding  from  the  last 
cervical  vertebra  (Fig.  39)  is  of  practical  importance  only  when  it  extends  to  the  first  rib  or  to 
the  sternum.  In  these  cases  the  subclavian  artery  is  placed  unusually  high  up,  since  it  runs  over 
this  supernumerary  rib  (as  it  ordinarily  does  over  the  normal  first  rib)  in  a  shallow  groove.  The 
pulsation  of  the  artery  may  consequently  be  easily  seen  or  felt  above  the  clavicle.  In  from  five 
to  ten  per  cent,  of  such  cases  this  anomaly  produces  symptoms  (violent  neuralgias  and  pares- 
thesias, or  thrombosis  and  aneurysm)  which  demand  operative  interference. 


FIG  *q  —Cervical  ribs.  The  seventh  cervical  vertebra  (indicated  by  the  figure  7)  articulates  with  a  small  cervical 
rib  upon  the  left,  and  with  a  complete  cervical  rib  upon  the  right  which  reaches  to  the  sternum.  The  figures  1  and  2 
indicate  the  first  two  thoracic  vertebrae. 

Inspection  and  Palpation  of  the  Thorax.— In  a  male  subject  in  whom  the  origins  of  the 
pectoralis  major  muscles  are  well  developed,  a  broad  shallow  furrow  may  be  seen  over  the  sternum. 
At  the  upper  end  of  the  sternum  this  anterior  median  furrow  passes  into  the  suprasternal  notch ; 
at  the  lower  end  of  the  sternum  it  is  continuous  with  the  so-called  scrobiculus  cordis  or  pit  of  the 
stomach*  In  the  latter  fossa,  which  may  be  quite  deep,  the  xiphoid  process  may  project 
anteriorly  or  may  have  an  inward  curve  endangering  the  liver.  The  sternal  angle,  or  the  angle 
of  Ludwig,  as  already  stated,  may  be  more  or  less  prominent  at  the  junction  of  the  manubnum 
and  the  gladiolus;  it  corresponds  to  the  attachment  of  the  second  rib  and  furnishes  the  starting- 
point  for  counting  the  intercostal  spaces.  In  the  female  the  anterior  median  furrow  (the  bosom) 
is  produced  by  the  presence  of  the  mammary  glands.     The  nipple  is  situated  at  the  level  of  the 

*  Both  of  these  designations  are  bad,  since  neither  the  heart  nor  the  stomach,  but  the  liver,  is  situated  beneath 
the  abdominal  wall  in  this  location. 


92 


TOPOGRAPHIC   AND    APPLIED   ANATOMY. 


fourth  rib  or  of  the  fourth  intercostal  space.  The  posterior  median  furrow  extends  downward 
from  the  vertebra  prominens.  It  is  produced  chiefly  by  the  prominences  of  the  long  muscles 
of  the  back.  In  this  furrow  may  be  felt  (or  seen  in  emaciated  subjects)  the  spinous  pro- 
cesses of  the  dorsal  vertebras.  The  clavicles  may  be  easily  outlined,  as  may  also  their  thickened 
sternal  ends  and  the  sternoclavicular  articulations.  The  infraclavicular  fossa  (Mohrenheim's 
fossa)  is  situated  below  the  junction  of  the  middle  and  outer  thirds  of  the  clavicle  and  corresponds 
to  the  groove  between  the  pectoralis  major  and  deltoid  muscles ;  it  is  more  distinct  in  individuals 
in  whom  there  is  a  marked  deviation  between  the  borders  of  these  muscles.  In  the  bottom  of 
this  fossa  the  costocoracoid  ligament  may  sometimes  be  felt,  running  approximately  parallel  with 
the  clavicle.      To  the  outer  side  of  this  ligament  is  the  coracoid  process,  covered  by  the  edge  of  the 

deltoid  muscle.  Passing  the  finger  outward  along  the  clavicle 
we  reach  the  acromion,  and  posteriorly  we  may  palpate  the 
spine  and  the  internal  and  inferior  angles  of  the  scapula.  Below 
the  spine  of  the  scapula  may  be  felt  the  eighth,  ninth,  tenth, 
and  eleventh  ribs.  The  edge  of  the  pectoralis  major  leaves  the 
anterior  thoracic  wall  and  forms  the  anterior  axillary  fold; 
posteriorly  the  edge  of  the  latissimus  dorsi  muscle  runs  upward 
and  forms  the  posterior  axillary  fold.  Below  the  axilla  may 
be  more  or  less  distinctly  seen  the  serrations  of  the  serratus 
magnus  muscle  which  interdigitate  with  those  of  the  external 
oblique  and  latissimus  dorsi  muscles.  If  the  trapezius  muscle 
is  put  upon  the  stretch  by  drawing  down  the  shoulder,  its  edge 
may  sometimes  be  seen,  in  lean  subjects,  passing  to  the 
spinous  process  of  the  twelfth  dorsal  vertebra. 

The  Bony  Thorax. — The  bony  thorax  is  the  firm  frame- 
work of  the  chest  and  is  shaped  like  a  truncated  cone  with 
the  base  downward  and  having  a  longer  frontal  and  a  shorter 
sagittal  diameter.  The  superior  aperture  of  the  thorax  is 
inclined  anteriorly;  its  boundaries  are  formed  by  the  upper 
margin  of  the  sternum,  by  the  first  pair  of  ribs,  and  by  the 
upper  margin  of  the  first  dorsal  vertebra.  The  relative  short- 
ness of  the  sagittal  diameter  of  this  opening  should  be  well 
borne  in  mind.  The  inferior  aperture  of  the  thorax  is  much 
larger;  its  boundaries  are  formed  by  the  xiphoid  process  of  the 
sternum,  by  the  costal  margin,  by  the  free  ends  of  the  eleventh  and  twelfth  ribs,  and  by  the  body 
of  the  twelfth  dorsal  vertebra.  The  inferior  aperture,  unlike  the  superior  one,  lies  in  two  planes 
which  form  an  angle,  the  apex  being  downward,  at  the  lowest  portion  of  the  costal  margin. 

The  bony  thorax  is  not  firm  enough  to  resist  temporary  or  permanent  changes  of  shape, 
which  may  be  produced  as  the  result  of  pressure  from  without  or  from  within.  The  deleterious 
effects  of  pressure  from  without  are  particularly  in  evidence  as  a  result  of  tight  lacing  (Fig.  40), 
against  which  it  is  the  duty  of  the  mother  and  of  the  physician  to  exert  a  sturdy  and  continuous 
opposition.     Since  the  lower  portion  of  the  bony  thorax  surrounds  some  of  the  abdominal  organs, 


Fig.  40. 


-A  thorax  deformed  by  lacing 
(after  Merkel). 


THE  THORACIC   WALL. 


93 


it  follows  that  injudicious  lacing  is  injurious  to  the  thoracic  and  abdominal  viscera.  Transitory 
pressure  from  without,  however,  may  be  very  great  without  overcoming  the  normal  elasticity 
of  the  bony  thorax*  Severe  crushes  of  the  chest  may  produce  a  laceration  of  the  heart,  of  the 
lungs,  and  of  the  liver  without  a  concomitant  fracture  of  the  bony  thorax.  As  a  result  of  the 
relative  increase  of  lime  salts,  fractures  of  the  bones  of  the  thorax  become  more  common  with 
advancing  age.  Prominence  of  definite  portions  of  the  bony  thorax,  arising  from  pressure  from 
within,  may  be  produced  by  cardiac  hypertrophy,  by  aortic  aneurysm,  by  tumors,  and  by  pleuritic 
exudates.  Localized  flattenings  and  depressions  may  be  brought  about  by  pulmonary  tuber- 
culosis and  by  old  pleuritic  adhesions.  Other  deformities  of  the  chest 
are:  The  chicken  breast  of  rachitis,  in  which  the  sternum  projects  ante- 
riorly ;f  the  thoracic  deformities  of  spinal  curvature  (kyphosis  and 
scoliosis);  the  flattened  and  narrow  chest  of  phthisis,  corresponding 
more  with  the  position  during  expiration;  and  the  barrel-shaped  chest 
of  emphysema,  corresponding  rather  with  the  position,  during  inspiration. 

Sternal  Region. — In  the  sternal  region  the  skin  is  but  slightly 
movable  and  the  underlying  connective  tissue  contains  but  little  fat. 
In  the  male  the  region  is  abundantly  covered  with  hair.  The  deep 
fascia  is  but  poorly  developed,  as  is  also  the  case  over  the  pectoralis 
major.  The  greater  the  development  of  this  muscle,  the  nearer  are  its 
origins  to  the  median  line,  and  the  more  marked  is  the  anterior  median 
furrow. 

The  sternum  is  covered  by  the  sternal  membrane  which  is  formed 
by  the  fibers  of  the  capsular  ligaments  of  the  sternocostal  joints  radiating 
into  the  periosteum.  The  bone  is  characterized  by  the  slight  develop- 
ment of  the  outer  compact  layers  and  by  the  preponderance  of  the 
spongy  substance.  Pressure-atrophy  is  consequently  easily  produced 
by  tumors  growing  from  within  the  chest  or  by  aortic  aneurysms. 
Mediastinal  abscesses  may  rupture  through  a  sternal  foramen  (Fig.  41), 
the  presence  of  which  is  dependent  upon  a  developmental  disturbance. 
These  foramina,  like  the  very  rare  congenital  fissures  of  the  sternum,  are 
also  important  from  a  medico-legal  standpoint,  since  a  comparatively 
slight  trauma  may  produce  a  severe  injury,  particularly  of  the  heart  and 
of  the  great  vessels.  The  synchondrosis  which  usually  lasts  throughout 
life  between  the  manubrium  and  gladiolus  is  so  firm  that  in  fractures 

of  the  sternum  (rare)  in  this  vicinity  pieces  of  bone  almost  always  remain  attached   to  the 
manubrium  or  gladiolus. 

The  important  artery  of  this  region,  the  internal  mammary,  ramifies  only  in  the  thoracic 
and  abdominal  walls,  although  it  gives  off  small  branches  (such  as  the  mediastinal  and  thymic 

*  Circus  performers  apparently  suffer  no  discomfort  from  having  some  one  hammer  upon  an  anvil  placed  upon 
the  chest. 

t  The  chicken  breast  stands  in  contrast  to  the  rare  funnel  breast,  in  which  the  sinking  in  of  the  body  of  the  sternum 
is  combined  with  a  projection  of  the  xiphoid  process  and  of  the  costal  margin. 


Fig.  41. — A  sternum 
with  a  foramen  in  the  lower 
portion  of  the  body  of  the 
bone. 


94  TOPOGRAPHIC   AND   APPLIED  ANATOMY. 

Fig.  42. — The  anterior  thoracic  wall  seen  from  within.     The  pleura  has  been  removed. 

Fig.  43. — The  right  intercostal  region.  In  the  upper  of  the  three  intercostal  spaces  represented  the  pleura  is  still 
intact;  in  the  second  it  has  been  removed;  in  the  third,  the  internal  intercostal  muscle  as  well  as  the  pleura  has  been 
taken  away. 

arteries)  and  the  comes  nervi  phrenici  artery,  which  runs  upon  the  pericardium  in  company  with 
the  phrenic  nerves.  The  artery  arises  as  the  first  branch  of  the  subclavian,  crosses  the  sternoclav- 
icular joint,  and  runs  downward  on  the  inner  surface  of  the  thoracic  wall,  one  centimeter  from 
the  margin  of  the  sternum,  to  the  sixth  intercostal  space,  where  it  divides  into  its  terminal  branches, 
the  musculophrenic  and  the  superior  epigastric  arteries  (the  latter  anastomose  with  the  inferior 
(deep)  epigastric  from  the  external  iliac).  The  most  important  branches  are  the  anterior  inter- 
costal, which  anastomose  with  the  intercostal  arteries  from  the  aorta,  and  the  perforating,  which 
pass  anteriorly  between  the  costal  cartilages  and  are  of  considerable  size  in  the  female  during 
lactation.  In  the  exposure  of  the  internal  mammary  artery  from  without  in  the  second,  third, 
or  fourth  intercostal  spaces,  the  following  structures  are  divided:  The  skin,  the  superficial 
fascia,  the  deep  fascia,  the  pectoralis  major  muscle,  the  intercostal  fascia,  and  the  internal  in- 
tercostal muscle.  From  within,  the  artery  is  covered  only  by  the  pleura;  to  the  inner  side 
of  the  artery  there  is  usually  a  single  vein.  Lower  down  the  venae  comites  lie  to  either  side  of 
the  artery,  and  the  vessels  are  separated  from  the  pleura  by  the  triangularis  sterni  muscle  (Fig. 
42).  Injuries  of  the  artery  in  the  upper  intercostal  spaces  are  consequently  more  apt  to  lead  to 
effusions  of  blood  into  the  pleural  cavity  (hemothorax)  than  similar  injuries  lower  down.  The 
deep  position  of  the  artery  makes  it  necessary  to  always  bear  in  mind  the  possibility  of  hemo- 
thorax after  injuries  in  this  region,  even  when  the  external  hemorrhage  is  slight.  Although  the 
vessel  is  so  well  protected  that  it  is  not  frequently  injured,  many  a  person  has  bled  to  death 
into  the  pleural  cavity  because  the  hemorrhage  was  not  recognized.  Upon  the  left  side  an  in- 
jury of  the  artery  in  the  fourth  or  fifth  intercostal  space  may  lead  to  hemorrhage  into  the  peri- 
cardial cavity,  since  in  this  situation  the  vessel  lies  upon  the  pericardium  instead  of  upon  the 
pleura. 

At  the  upper  margin  of  the  sternum  the  relation  of  the  sternoclavicular  articulation  to  the 
large  vessels  and  to  the  contents  of  the  superior  aperture  of  the  thorax  (see  Plates  11,  13,  and  16) 
must  be  borne  in  mind,  particularly  with  reference  to  the  backward  dislocation  of  the  sternal  end 
of  the  clavicle.  In  this  dislocation  the  sternal  end  of  the  clavicle  may  press  backward  upon  the 
subclavian  artery  and  vein,  the  common  carotid  artery,  the  internal  jugular  vein,  the  trachea,  and 
the  esophagus,  and  lead  not  only  to  compression  of  the  vessels  but  also  to  dyspnea  and  dysphagia. 

The  Lateral  Thoracic  Wall. — The  mammary  gland  of  the  male  is  practically  devoid  of 
interest.  The  mammary  gland  of  the  female  lies  upon  the  pectoralis  major  between  the  third 
and  seventh  ribs  and  possesses  from  fifteen  to  twenty  secretory  ducts  which  converge  toward 
the  nipple  and  have  dendritic  ramifications.  In  opening  mammary  abscesses  (after  mastitis) 
the  incisions  should  consequently  be  made  to  radiate  from  the  nipple  in  order  to  avoid  injuring 
these  ducts. 

The  arteries  0}  the  mammary  gland  reach  their  most  marked  development  during  the  height 
of  lactation.  They  originate  from  three  sources:  (1)  From  the  perforating  branches  of  the  in- 
ternal mammary  artery  in  the  upper  five  intercostal  spaces,  but  particularly  in  the  second  and 


Incisura  jugularis  Incisura  clavicularis  sterni 


Sternal  lymphatic  gland 
Internal  mammary  artery 
Internal   mammary  vein 


Supracostal  branch 


Posterior  branch  --- 
Communicating  branch  — 

M.  intercostalis  int.  •-- 

Intercostal  vein  _  - 
Intercostal  artery  ■-- 
Intercostal  nerve  ■ 


Fig.  42. 


M.  triangularis  sterni 


%■  4/- 


Pleura  (cut  edge) 
Sympathetic  nerve 

Intercostal  vein 
Intercostal  artery 


Azygos  major  vein 


Sympathetic  ganglion 


Great  splanchnic  nerve 


THE   THORACIC   WALL.  95 

third;  (2)  from  the  long  thoracic  branch  of  the  axillary  artery;  (3)  from  the  perforating  branches 
of  the  upper  intercostal  arteries.  The  deep  veins  accompany  the  arteries;  the  subcutaneous 
veins  form  a  large-meshed  network  and,  in  the  female,  may  frequently  be  seen  through  the  skin. 
They  form  the  plexus  venosus  mammilla  (circulus  venosus  Halleri)  about  the  nipple  and  empty 
above  into  the  external  jugular  vein;  they  also  empty  into  the  long  thoracic,  thoracico-epigastric, 
and  internal  mammary  veins. 

The  lymphatic  vessels  of  the  mamma  are  very  numerous  and  form  superficial  and  deep 
networks.  The  greater  portion  of  the  lymph  drains  into  the  axillary  lymphatic  glands*  These 
glands  are  involved  in  affections  of  the  mammary  gland  of  the  same  side,  and  they  are  consequently 
removed  together  with  the  breast.  In  rarer  cases  they  also  become  involved  in  affections  of  the 
opposite  mammary  gland,  since  the  lymphatic  vessels  of  both  breasts  anastomose  in  the  median 
line.  A  portion  of  the  lymph  passes  internally  to  the  intercostal  lymphatic  vessels  and  in  this 
manner  reaches  the  lymphatic  glands  of  the  thoracic  space. 

The  deep  nerves  of  the  gland  accompany  the  larger  lactiferous  ducts  and  are  much  less 
numerous  than  the  cutaneous  nerves.  The  cutaneous  nerves  are  furnished  partly  by  the  supra- 
clavicular branches  of  the  cervical  plexus,  but  chiefly  by  the  anterior  and  lateral  cutaneous 
branches  of  the  second  to  the  sixth  intercostal  nerves.  The  connection  between  the  second  and 
third  lateral  cutaneous  branch  (intercosto-humeral  nerve)  and  the  lesser  internal  cutaneous  nerve 
explains  the  occasional  occurrence  of  pain  radiating  to  the  region  of  the  elbow  or  still  lower  in 
diseases  of  the  mammary  gland  (tumors,  neuralgia  of  the  mammary  gland).  In  the  extirpation 
of  the  mammary  gland  and  the  diseased  axillary  tissues  the  following  structures  should  be  par- 
ticularly avoided:  the  axillary  artery  and  vein,  the  long  thoracic  artery,  the  subscapular  artery, 
the  long  subscapular  nerve  (division  produces  paralysis  of  the  latissimus  dorsi  muscle),  and  the 
long  thoracic  nerve  (division  is  followed  by  paralysis  of  the  serratus  magnus  muscle): 

The  arteries  of  the  lateral  thoracic  wall  are  external  and  internal. 

The  external  surface  of  the  lateral  thoracic  wall  is  supplied  chiefly  by  the  branches  of  the 
axillary  artery  (Fig.  29).     The  following  vessels  should  be  noted: 

1.  The  acromiothoracic  artery,  which  lies  beneath  the  infraclavicular  fossa,  where  the  vessel, 
together  with  its  numerous  branches,  is  endangered  in  the  ligation  of  the  first  portion  of  the 
axillary.  The  vessel  arises  at  the  upper  margin  of  the  pectoralis  minor  and  immediately  divides 
into  a  number  of  branches.  The  pectoral  branches  ramify  in  the  muscles  of  the  chest ;  if  such 
a  branch  arises  from  the  axillary  higher  up  (comparatively  rare)  it  is  known  as  the  superior 
thoracic  artery.  The  acromial  branch  runs  transversely  outward,  perforates  the  deltoid  muscle, 
and  ends  in  the  anastomosis  over  the  acromion.  The  descending  or  humeral  branch  accom- 
panies the  cephalic  vein  in  the  groove  between  the  pectoralis  major  and  deltoid  muscles. 

2.  The  long  thoroxic  artery,  which  arises  from  the  axillary  beneath  the  pectoralis  minor 
muscle.  The  artery  leaves  the  outer  border  of  this  muscle  and  runs  downward  to  the  fifth  or 
sixth  intercostal  space,  somewhat  posterior  to  the  margin  of  the  pectoralis  major,  upon  the  ser- 

*  The  lymphatic  gland  %vhich  is  usually  first  involved  in  carcinoma  is  situated  beneath  the  border  of  the  pectoralis 
major  muscle'upon  the  third  serration  of  the'serratus  magnus  (third  rib).  The  lymphatic  glands  extend  upward  beyond 
the  axillary  vein  and  beneath  the  clavicle,  in  which  position  their  removal  is  necessarily  difficult.  Posteriorly,  the  glands 
accompany  the  subscapular  artery  and  the  nerves  of  the  same  name. 


96  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

PLATE    6. 

A  posterior  view  of  the  opened  head,  neck,  and  trunk  of  a  man.  The  greater  portion  of  the  brain  has  been 
removed;  the  spinal  cord  and  spinal  nerves  as  well  as  the  viscera  and  diaphragm  may  be  seen  in  situ.  From  a 
Leipzig  model  from  nature  (His). 

ratus  magnus  muscle,  which  it  supplies.  This  artery  varies  in  size  and  is  often  absent.  The 
mammary  branches  of  this  vessel  have  been  previously  mentioned.  The  long  thoracic  nerve, 
for  the  serratus  magnus  muscle,  does  not  run  with  the  artery  but  somewhat  posteriorly  [that  is, 
in  the  angle  made  by  the  inner  and  posterior  walls  of  the  axilla. — Ed.],  covered  by  the  latissi- 
mus  dorsi  muscle. 

3.  The  subscapular  artery,  the  largest  branch  of  the  axillary,  arises  to  the  outer  side  of  the 
long  thoracic  artery  at  the  axillary  border  of  the  scapula.  It  is  covered  by  the  latissimus  dorsi 
muscle  and  is  not  endangered  by  operative  procedures  in  the  axilla  until  they  penetrate  beneath 
the  margin  of  this  muscle.  One  of  the  terminal  branches,  the  thoracicodor sails,  runs  onward 
in  the  continuation  of  the  main  trunk,  as  the  largest  artery  of  the  lateral  thoracic  wall,  between 
the  serratus  magnus  and  latissimus  dorsi  (and  teres  major)  to  supply  these  muscles.  The  other 
terminal  branch,  the  dorsalis  scapula,  passes  posteriorly  through  the  triangular  space  (see  page 
76)  to  reach  the  dorsal  surface  of  the  scapula. 

The  arteries  running  upon  the  internal  surface  of  the  thoracic  wall  are  known  as  the  inter- 
costal arteries.    These  vessels  originate  from  three  sources: 

1.  From  the  costocervical  trunk  of  the  subclavian  (see  page  70)  is  given  off  the  small  supe- 
rior intercostal  artery,  which  descends  beneath  the  pleura  in  front  of  the  necks  of  the  first  two 
ribs  and  supplies  the  two  upper  intercostal  spaces. 

2.  The  thoracic  aorta  gives  off  nine  intercostal  branches,  for  the  third  to  the  eleventh  inter- 
costal spaces  inclusive,  and  a  tenth  branch  for  the  lower  margin  of  the  twelfth  rib.  These  vessels 
arise  from  the  dorsal  surface  of  the  thoracic  aorta.  As  the  aorta  lies  to  the  left  side  of  the  ver- 
tebral column,  the  right  intercostal  arteries  are  longer  than  the  left  ones.  The  vessels  of  the 
right  side  pass  over  the  vertebra  toward  the  right  and  are  situated  behind  the  esophagus,  the 
vena  azygos  major,  and  the  right  sympathetic  nerve.  The  shorter  vessels  of  the  left  side  are 
behind  the  vena  azygos  minor  and  the  left  sympathetic  nerve.  At  the  necks  of  the  ribs  the 
arteries  give  off  posterior  branches  which  run  backward  and  divide  into  a  spinal  branch,  entering 
the  vertebral  canal  through  the  intervertebral  foramen  and  supplying  the  spinal  cord,  and  a 
muscular  and  cutaneous  branch.  The  continuation  of  the  artery  or  the  anterior  branch,  usually 
designated  simply  as  the  intercostal  artery,  runs  in  the  intercostal  groove  along  the  inferior  border  of 
the  rib,  at  first  being  covered  only  by  the  pleura,  and  then  passes  anteriorly  between  the  internal 
and  external  intercostal  muscles;  it  sends  a  small  branch  to  the  upper  border  of  the  rib 
below,  gives  off  cutaneous  branches  which  appear  externally  (with  mammary  branches,  see  page 
94),  and  anastomoses  with  the  anterior  intercostal  branches  of  the  internal  mammary  artery. 

3.  The  anterior  intercostal  branches  of  the  internal  mammary  artery,  which  pass  backward 
and  anastomose  with  the  aortic  intercostals.  These  vessels  run  in  the  upper  six  intercostal 
spaces,  the  lower  six  being  supplied  with  corresponding  branches  by  the  musculophrenic  artery. 

The  intimate  relation  of  the  intercostal  arteries  with  the  intercostal  grooves,  which  furnish 
them  with  an  external  bony  protection,  explains  the  following  statements:     (1)   Injuries  of  the 


Cranial  cavity 
Thalamus  opticus 
Pineal  gland 
Aqueduct  of  Sylvius 


Lobus  ir&wer  ,obe  of  left  lung 


Superior  gluteal  n 
Gluteus  maximus  m 

Tendon  of  pyriformis 
Gemellus  superior  m. 
Obturator  intemus  m. 
Gemellus  inferior  m. 

Quadratus  femoris  m 


f-atissimus  m. 
Serratus  magnus  m. 


Seventh  cervical 
vertebra 
Eighth  cervical  n. 

First  dorsal  n. 
Brachial  plexus 

Axillary  artery 
Axillary  vein 


Twelfth  dorsal  vertebra 

Twelfth  dorsal  n 
First  lumbar  vertebra 


Quadratus  lumborum  m. 
Fifth  lumbar  n 
First  sacral  vertebra 
KrstlAcra)  m. 


Gluteus  minimus  m. 
Superior  gluteal  a. 


I'irst  coccygeal  vertebra 

Internal  pudic  artery 
Great  tro<hanter 
Levator  ani  m. 
Great  sciatic  nerve 


96 


/ 


\ 


tii'si  UinaiO- 


atioilqn  aom*lBi!T— 

...        ,  ■!_ 


: •Writ?'"  JjuIwuiiA" 


.     B    6. 

. 

m  .   and 


m»  k*«  bimr*- 


.V    U <.[|J»U( 

.m  biotesmob'nlTomo)?  - 


— •  mei/Honed.    Th 


run  \\  idi  tilt*  UlU'iX  liflf  >^'qii 


—  f  of  the  fxilla. — Ed.].  .  by  the  - 


>  HuwYse 

mdslw 


branch  of  the  axilla?" 

.a  ftuimb  didsia^cy^ 1 —  iiT  Ot"  the  SCapula^ 

•ccdures  in  the  axilla  until"! 


)f  the 

imuri  lo  boH 


.n  Ira**  trOT 

w»iri  UHxnfi  -4——~ — '  'ne  of  the  terminal  branches,  the  tho;  __JV.«t  bkahu 

■  -rHfrf.-/ — b*h*  trunk,  as  .the  largest  art  pry  of  \\\?  latpml  ihf*r    i    "\}r  H-'-ti" 

i I — amus  dorsi  (and  teres  major)  to  supply  these  muscl       I 

/  lorsalis  scapula,  passes  posteriorly  through  ffie  ~~ y"Jn  ril 

/  I  surface  of  I 

t     running  upon  the  internal  surface  of  the  thoracic  wall  are  knowj>e£thc 

.     jRhes&Jpfsels  originate  from  three  sources  _ N«==^nui  iwio sdoi -»woJ 

•^toHf'^Umli'al  trunk  of  the  subclavian  (see  page  70)  is  givtn  off  ti 
rior         -"'^^^ftW^-nlikli    •  beneath  the  pleura  in  front  of  the/iecks  of  th 

ribs  i  >lies  the  two  upper  intercostal 

The  thoracic  aort     1  (T  nine 

costa  ^ffiffirmi  .1      ■ .  . I  ■■  "vrtft**]- 

.n  dfett^hi^wiaji-Lu 1 — , .    \i.     As  the  aorta  lies  to/the  l< 

mdsm-/ mimirf  rrn-i^^i {  longer  than  rtir-1 4 ln  d'U3"T 

I  L 

•<>nhi;l  trfjuH \ •  * f ymbii  tlaJ 


.n  DiiJa£8u"|'<iloilI . 


5,  the 


.rn  min(x!(nul  KuinfosoO 
a  wdmu\  rftli'-l . 


.rn  aim 


1    ndan>v  l»a ' 

r>i 

them 

snsfl  Dili. 1 


<;unA 


.  .  fri  1o[J 


imiorml 
.tn  <-.uji.iI  I 





;u«  eulIwnaO 

'     .    r,      •  Bll/JdO 


m  ahom-jl  Miinbfiuy 


Cavum   cranii 

^Thalamus  opticus 
Glandula  pinealis 
Aquaeductus  cerebri 


__  Atlas 
^ ..    N.  cervicalis  II 
A.  vertebralis 
V.  jugularis  communis 
M.  sternocleidomastoideus 


Costa  I 
Caput  humeri 

M.  deltoides. 

Lobus  superior  y_ 
pulm.  sin. 


Tab.6. 


Vertebra  cervicalis  VII 
N.  cervicalis  VIII 
„N.  thoracalis  I 
Plexus  brachialis 
A.  axillaris 

V.  axillaris 


M.  latissimus 

M.  serratus  anterior 


N.  glutaeus  sup.__ 
M.  glutaeus  maximus 

Tendo  m.  piriformis... 
M.  gemellus  sup. 
M.  obturator  internus 
M.  gemellus  inf. 

M.  quadratus  femoris —LI 


yertebra  thoracalis  XII 

N.  thoracalis  XII 
Vertebra  lumbalis  I 

Ren  dexter 

N.  iliohypogastricus 


M.  quadratus  lumborum 
N.  lumbalis  V 
Vertebra  sacralis  I 
N.  sacralis  I 

M.  glutaeus  minimus 

A.  glutaea  sup. 

Vertebra  coccygea  I 

A.  pudenda  communis 
Trochanter  major 

.M.  levator  ani 
N.  ischiadicus 


THE  THORACIC  WALL.  g~ 

intercostal  arteries  without  concomitant  injuries  of  the  ribs  are  rare.  (2)  In  resection  of  a  por- 
tion of  a  rib,  the  arteries  should  be  carefully  avoided  by  shelling  out  the  bone  from  the  perios- 
teum (subperiosteal  resection)  and  exercising  great  care  at  the  lower  costal  margin.  (3)  In 
opening  the  pleural  cavity  the  instrument  should  be  introduced  in  the  middle  of  the  intercostal 
space,  avoiding  the  margin  of  the  rib.  (4)  In  fractures  of  the  rib  the  artery  may  occasionally 
be  lacerated;  in  rare  cases  the  internal  intercostal  muscles  and  the  pleura  may  also  be  torn  and 
a  fatal  effusion  of  blood  take  place  into  the  pleural  cavity  (hemothorax).  (5)  It  is  usually 
necessary  to  resect  a  portion  of  a  rib  in  order  to  expose  the  intercostal  artery  from  without. 

On  account  of  the  free  anastomosis  of  the  anterior  and  posterior  intercostal  arteries,  it  is 
possible  in  compression  or  stenosis  of  the  thoracic  aorta  (by  tumors,  for  example)  for  the  blood 
from  the  inner  surface  of  the  thoracic  wall  to  gain  access  to  the  aorta  below  the  site  of  the  com- 
pression through  the  dilated  internal  mammary  artery  and  the  anastomoses  between  the  ribs. 

The  veins  of  the  thoracic  wall  consist  of  those  which  accompany  the  arteries  and  are  called 
by  the  same  names  (intercostal  veins,  Fig.  43)  and  of  the  cutaneous  veins.  The  costo-axillary 
veins  are  situated  over  the  upper  intercostal  spaces  and  allow  the  blood  from  the  intercostal 
veins  to  pass  into  the  axillary  vein.  The  thoraco-epigastric  veins  are  also  of  importance;  one  of 
these,  the  vena  thoraco-epigastrica  tegumentosa  longa  (Braune),  runs  in  the  anterior  axillary 
line  and  forms  a  subcutaneous  connection  between  the  femoral  and  axillary  veins. 

The  sensory  nerves  of  the  thoracic  wall  are  furnished  from  several  sources.  The  region 
near  the  posterior  median  furrow  is  supplied  by  the  posterior  branches  of  the  dorsal  nerves, 
the  skin  of  the  infraclavicular  region  obtains  its  nerve-supply  from  the  supraclavicular  branches 
of  the  cervical  plexus,  and  the  remainder  of  the  thoracic  wall  is  provided  with  sensation  by  the 
intercostal  nerves.  The  intercostal  nerves  (Fig.  43)  are  the  anterior  divisions  of  the  dorsal  spinal 
nerves.  Alongside  of  the  vertebral  column  they  run  upon  the  inner  surface  of  the  external  in- 
tercostal muscles  immediately  beneath  the  pleura  and  are  consequently  exposed  to  irritation 
in  inflammation  of  this  membrane.  At  the  angle  of  the  rib,  where  the  free  border  of  the  internal 
intercostal  muscle  commences,  they  pass  between  and  supply  the  two  intercostal  muscles,  and 
follow  the  lower  margin  of  the  rib,  being  situated  below  the  intercostal  artery.  Their  proximity 
to  the  ribs  explains  the  occasional  occurrence  of  neuralgic  pains  in  costal  fractures.  In  the  lat- 
eral region  of  the  thorax  they  give  off  the  lateral  cutaneous  nerves  which  subdivide  into  an 
anterior  and  a  posterior  branch  (read  the  description  of  the  nerves  of  the  mammary  gland). 
Anteriorly,  beside  the  sternum,  their  terminal  branches  pass  between  the  costal  cartilages  to  the 
skin  of  the  sternum  region  as  the  anterior  cutaneous  nerves. 

The  motor  nerves  of  the  thoracic  wall,  with  the  exception  of  the  intercostal  nerves  supply- 
ing the  intercostal  muscles  and  the  branches  to  the  long  muscles  of  the  back,  are  branches  of  the 
brachial  plexus.  This  plexus  receives  almost  the  entire  anterior  division  of  the  first  dorsal 
nerve.  This  nerve  is  situated  in  the  thorax  at  the  point  where  it  passes  over  the  neck  of  the  first 
rib,  and  is  occasionally  compressed  by  tumors  (aortic  aneurysm)  and  gives  rise  to  violent  pains 
in  the  arm.  The  long  thoracic  nerve,  which  is  given  off  from  the  brachial  plexus  and  runs  upon 
the  serratus  magnus  muscle,  and  the  long  subscapular  nerve  (for  the  latissimus  dorsi  muscle), 
which  accompanies  the  subscapular  artery,  have  been  previously  described  (see  pages  75  and 
76).     The  branches  for  the  pectoralis  major  and  minor  and  for  the  subclavius    muscles  are 


98 


TOPOGRAPHIC    AND    APPLIED   ANATOMY 


PLATE  7. 

A  posterior  view  of  a  dissection  of  the  thoracic,  and  of  a  portion  of  the  cervical  viscera, 
arteries,  and  veins  at  the  hilus  of  the  lungs.     From  a  Leipzig  model  from  nature  (His). 


The  relation  of  the  bronchi, 


occasionally  encountered  in  the  infraclavicular  fossa  in  ligating  the  first  portion  of  the  axillary 
artery  (see  page  73  and  Fig.  28). 

The  Inferior  Boundary  of  the  Thorax. — The  diaphragm  forms  a  muscular  dome-shaped 
partition  which  constitutes  the  inferior  boundary  of  the  thorax.  The  right  side  of  the  dome, 
which  covers  the  liver,  projects  upward  more  markedly  than  does  the  left  side.  The  central 
tendon  is  flatter  and  has  a  more  restricted  range  of  motion  during  respiration  (review  the  lumbar, 
costal,  and  sternal  portions  of  the  muscle  with  their  origins).     The  structures  passing  through 


Vertebral  arch 
Spinal  cord 

Body  of  vertebra 


Vena  azygos. 

major 

Esophagus 

Right  inferior 

pulmonary  vein 

Right  phrenic  f  ' 

nerve         \ ' 

Foramen  quad-- 

ratum 


.  Vena  azygos 
minor 
Thoracic 
descending  aorta 


-  Diaphragm 


—  Pericardium 


Left  phrenic 
nerve 


Sternum 


Fig.  44. — The  diaphragm  and  the  inferior  half  of  the  pericardium  seen  from  above.     Formalin  preparation  (child). 


the  diaphragm  from  above  downward  are:  the  descending  aorta  through  the  aortic  opening; 
the  esophagus  and  the  pneumogastric  nerves  through  the  esophageal  opening;  the  splanchnic 
nerves,  from  the  sympathetic,  between  the  crus  mediale  and  the  crus  intermedium  of  the  lum- 
bar portion;  the  sympathetic  nerve  itself  between  the  crus  intermedium  and  the  crus  laterale 
of  the  lumbar  portion;  and  the  superior  epigastric  artery,  from  the  internal  mammary  between 
the  sternal  and  costal  portions  (the  so-called  fissure  of  Larrey).  The  structures  passing  through 
the  diaphragm  from  below  upward  are:  the  inferior  vena  cava  (accompanied  by  a  filament  from 
the  right  phrenic  nerve),  through  the  foramen  quadratum  in  the  right  side  of  the  central  tendon; 
the  vena  azygos  major  (on  the  right  side)  and  the  vena  azygos  minor  (on  the  left  side),  accom- 


Scalenus  antic  us  m. 

First  rib 
Left  subclavian  a. 
Left  subclavian  v. 


Trachea  , 


Upper  lol>e  of  left  lung . 
»      Arch  of  aorta 

Left  pulmonary  a-- 
Left  bronthus- 


Latissimus  dorsi  m. 
Left  inferior  pulmon- 
ary v. 


Lower  lobe  of  left  lung. 


Ninth  rib . 
Esophagus- 


:  . 


Right  intenai  jugular  v. 


Right  common  carotid  a. 


Pharynx 
Esophagus 


Great  cardiac  vein 
Atari'        U'ft  auricle 
Right  pulmonary  artery 


-  Head  of  humerus 
I'ci  i oralis  major  m. 

•  .lis  minor  m. 

—  Superior  vena  cava 

lobe  of  right 
lung 
.AiyjB-inaj  >r  \ 

plflUS 


rial  bronchus 
_  Ki«  hi  superior  pul 

mi  'M.irv 
•  HyparU-rial   bronchus 


]  MiflHI  <1<>rsi  rn 
Riliht  infrtinr  pul- 
monary V. 

Serratus  magnus  m. 


Lower  lol*  of  right  lung 


dex 


Diaphragm 


sbivflD  rs 


gimmud  If 
.in  -wiem  ■MotuUjI 
.m  -Kinirn  *ilj;-ioii-,'l. 


Jdgh  )o  -*lol  T*|i|  )  _ 
snol 
.v  loifirn  * 

zui'ilq  liiid  jinil 

RuHininJ  ten 

.7  <T6nom 
gurijaoiri   Uh 


.m  isioh  autni 
-luq  Tomlni  irfgiM 
.  /  yisnom 

.rn  aunjjBtn  «ulim'j<; 
gmri  Irish  lt>  :>lul  smoJ 


.7    1UI|J3U(    ll.IlT)'!' 

,m  bio»« 

.    j 


>.  irfa<H 


inmoD  triaiH 


ms£iriii>ii(I 


•  nihil 
l-ivi.  I 


llaJ 


.awfonon 


no/nln 


■    BWOJ 


ifii  rilai"/. 

—  £Ug£riqoe3 


m  belo 


Tab  7. 


V.  jugularis  int.  dex. 

M.  sternocleidom. 


M.  scalenus  ant. 

Costa  I 

A.  subclavia  sin~ 
V.  axillaris  sin.. 

Trachea 

,obus  sup.  pulm.  sin. 
Arcus  Aortae 
A.  pulm.  sin. 
Bronchus  sin. 


M.  latissimus  dorsi 
V.  pulm.  inf.  sin. 


Lobus  inf.  pulm.  sin 


Costa  IX 
Oesophagus 


A.  carotis  com.  dex 

Pharynx 
Oesophagus 


y.  jugularis  ex. 

A.  subclavia  dex. 

M.    subclavius 


V.  cordis  magna 
Atrium  sinistrum 


V.  cava  inf. 
Hepar 


Clavicula 

,  Caput  humeri 
\  M.  pect.  maj. 
i  M.  pect.  minor 

V.  cava  sup. 

Lobus  sup. pulm. dex. 

V.  azygos 
>  Plexus  brachialis 

Bronchus  eparteriatts 

V.  pulm.  dex.  sup. 
Bronchus  hyparterialis 

M.  latissimus  dorsi 
V.  pulm.  dex.  inf. 
M.  8erratus  ant. 
Lobus  inf.  pulm.  dex. 


Diaphragma 


A.  pulm.  dex 


THE  CONTENTS  OF  THE  THORAX.  gn 

panying  the  splanchnic  nerves  through  the  lumbar  origin  (crura)  of  the  muscle;  the  thoracic 
duct,  through  the  aortic  opening;  and  the  superior  epigastric  veins  through  the  fissure  of  Larrey. 

The  arteries  supplying  the  upper  surface  of  the  diaphragm  are  the  comes  nervi  phrenici 
(pericardiaco-phrenic  artery,  see  Plate  8,  a)  and  the  musculophrenic,  one  of  the  two  terminal 
branches  of  the  internal  mammary.  The  blood-supply  of  the  lower  surface  of  the  diaphragm 
is  furnished  by  the  phrenic  arteries,  which  arise  from  the  aorta  in  the  aortic  opening  or  from  the 
celiac  axis. 

The  phrenic  nerves  from  the  cervical  plexus  may  be  easily  found  in  the  neck  upon  the  anterior 
surface  of  the  scalenus  anticus  muscle.  In  the  chest  they  run  upon  the  pericardium  and  are 
covered  by  the  pleura  mediastinalis  (Plate  8).  The  diaphragm  also  receives  branches  from  the 
seventh  to  the  twelfth  intercostal  nerves. 

The  central  portion  of  the  upper  surface  of  the  diaphragm  is  adherent  to  the  pericardium ; 
the  lateral  portions  are  attached  to  the  pleural  sacs  (diaphragmatic  pleura).  The  pericardial 
sac  is  in  relation  with  the  central  tendon,  but  also  extends  to  the  left  over  the  muscular  portion 
of  the  diaphragm  (Fig.  44).  Since  the  left  lung  is  not  so  voluminous  as  the  right,  the  left  dia- 
phragmatic pleura  is  not  so  extensive  as  the  corresponding  layer  upon  the  right  side. 

Diaphragmatic  hernias  are  produced  when  abdominal  viscera  pass  into  the  thorax  through 
the  diaphragm.  They  may  be  congenital  or  acquired.  The  favorite  site  for  such  hernias  is 
in  the  vicinity  of  the  esophageal  foramen,  in  which  the  esophagus,  in  contrast  to  the  aorta  and 
vena  cava,  is  fixed  by  only  a  loose  connective  tissue.  Such  hernias  are  usually  left-sided,  since 
the  liver  is  situated  immediately  below  the  right  dome  of  the  diaphragm.  They  may  contain 
the  stomach,  the  omentum,  the  large  intestine,  the  small  intestine,  the  spleen  and  other  viscera. 
The  peritoneum,  which  lines  the  under  surface  of  the  diaphragm,  is  protruded  into  the  thorax 
and,  together  with  the  pleura,  forms  the  sac  of  the  hernia.  Such  a  hernial  sac  is  wanting  when 
one  of  the  abdominal  viscera  enters  the  thoracic  cavity  through  a  complete  tear  in  the  diaphragm ; 
this  is  the  condition  of  affairs  in  the  majority  of  cases  of  diaphragmatic  hernia.  There  have 
been  individuals  in  whom  the  stomach  has  been  situated  above  the  diaphragm  for  many  years. 

As  the  inferior  vena  cava  is  firmly  fixed  in  the  foramen  quadratum,  a  marked  left-sided 
pleural  exudate  may,  by  pushing  the  heart  over  to  the  right,  bend  the  vena  cava  to  almost  a 
right  angle.  This  may  produce  symptoms  of  cerebral  anemia,  unconsciousness,  or  even  death. 
At  the  same  time,  symptoms  of  venous  stasis  will  appear  in  the  lower  extremities.  It  should 
also  be  remembered  that  the  diaphragm  reaches  much  lower  at  the  vertebral  column  than  ante- 
riorly at  the  sternum,  so  that  horizontal  penetrating  wounds  may  open  the  abdominal  cavity 
in  front  and  a  pleural  cavity  behind  (see  Plate  13). 

THE  CONTENTS  OF  THE  THORAX. 

The  greater  portion  of  the  inner  surface  of  the  thoracic  wall  is  lined  by  the  pleura.  This 
forms  two  sacs  or  cavities,  the  right  and  the  left  pleural  cavities,  which  are  completely  separated 
from  each  other  and  almost  entirely  filled  by  the  right  and  left  lungs.  The  lungs  are  so  closely 
applied  against  the  pleural  surface  that  injuries  of  the  pleura  without  concomitant  injury  of  the 
lung  are  comparatively  rare.     The  pleura  lining  the  inner  surfaces  of  the  ribs  and  the  inter- 


IOO  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

Fig.  45. — A  diagrammatic  representation  of  the  projections  of  the  heart,  of  the  pleural  limits,  and  of  the  lungs 
upon  the  anterior  thoracic  wall.  The  lung  is  indicated  by  yellow,  and  the  pleura  by  red  lines.  The  lungs  are  represented 
in  a  state  of  moderate  distention,  so  that  their  borders  correspond  to  a  position  between  deepest  expiration  and  deepest 
inspiration. 

Fig.  46. — A  diagrammatic  representation  of  the  projections  of  the  pleural  limits,  of  the  lungs,  and  of  the  bifurcation 
of  the  trachea  upon  the  posterior  thoracic  wall.     The  lung  is  indicated  by  yellow  and  the  pleura  by  red  lines. 


costal  spaces  is  designated  as  the  costal  pleura,  while  that  situated  upon  the  upper  surface  of 
the  diaphragm  is  known  as  the  diaphragmatic  pleura.  The  costal  pleura  forms  the  outer  wall 
of  the  pleural  cavity,  while  the  diaphragmatic  pleura  forms  its  floor.  The  inner  wall  is  known 
as  the  mediastinal  pleura;  it  extends  in  a  sagittal  plane  from  the  vertebral  column  toward  the 
sternum,  and  in  these  situations  becomes  continuous  with  the  costal  pleura.  The  costo-medi- 
astinal  sinus  is  situated  anteriorly  at  the  junction  of  the  costal  and  the  mediastinal  pleurae.  The 
costo-phrenic  sinus  (Fig.  49)  is  formed  by  the  reflection  of  the  costal  pleura  upon  the  diaphragm. 
The  sinuses  are  complementary  spaces  for  the  accommodation  of  the  margins  of  the  lungs  dur- 
ing inspiration.  During  respiration  the  lungs  glide  inaudibly  upon  the  smooth  inner  surface 
of  the  pleura.  If  inflammatory  exudates  are  deposited  upon  the  pleura,  however,  the  physician 
may  hear  friction  sounds  through  the  thoracic  wall. 

Owing  to  the  thinness  of  the  thoracic  wall,  pathologic  changes  in  the  breathing  space  or 
in  the  lung-tissue  or  abnormal  collections  in  the  pleural  sacs  may  be  recognized  by  typical  varia- 
tions from  the  normal  pulmonary  sounds.  The  pleural  cavity  may  contain  air,  entering  through 
an  external  wound,  but  more  frequently  through  a  bronchus  after  injury  to  the  lung  (pneumo- 
thorax), a  serous  transudate  (hydrothorax),  pus  (empyema),  or  blood  (hematothorax). 

The  costal,  diaphragmatic,  and  mediastinal  pleurae  together  form  the  parietal  pleura,  in 
contradistinction  to  the  visceral  pleura,  which  is  intimately  adherent  to  the  surface  of  the  lung. 
The  two  layers  are  continuous  with  each  other  at  the  root  of  the  lung. 

The  mediastinal  pleura  is  best  studied  by  removing  the  lateral  walls  of  the  thorax,  together 
with  the  costal  pleura,  and  taking  out  the  lungs  by  cutting  through  their  roots  (and  also  through 
the  small  and  insignificant  ligamentum  latum  pulmonis,  which  runs  downward  from  the  root 
of  the  lung  to  the  diaphragm).  It  will  then  be  seen  that  the  two  mediastinal  pleurae  form  a  par- 
tition between  the  two  pleural  cavities  which  is  not  exactly  in  the  median  line  and  which  extends 
from  the  vertebral  column  to  the  sternum.  This  is  the  mediastinum*  It  consists  of  the  two 
layers  of  the  mediastinal  pleura  and  of  the  space  enclosed  between  them.  Superiorly,  where 
the  mediastinal  pleura  becomes  continuous  with  the  costal  pleura  above  the  superior  aperture 
of  the  thorax,  the  mediastinal  contents  become  continuous  with  the  structures  of  the  neck;  in- 
feriorly,  the  mediastinum  is  fixed  to  the  diaphragm. 

The  dome  of  the  pleura  extends  upward  posteriorly  to  the  level  of  the  upper  margin  of  the 
first  thoracic  vertebra,  and  slopes  down  anteriorly  to  the  upper  margin  of  the  first  costal  carti- 

*  Among  the  old  anatomists  the  word  "mediastinum"  was  equivalent  to  "partition";  for  example,  mediastinum 
auris-membrana  tympani.  As  the  diaphragm  is  a  horizontal  partition  between  the  thorax  and  abdomen,  so  is  the  medias- 
tinum a  vertical  partition  in  the  thorax.  It  is  formed  by  the  two  layers  of  mediastinal  pleura,  which  barely  touch  at 
any  point,  but  which  enclose  a  space  completely  filled  by  many  organs.  A  "  mediastinal  cavity  "  consequently  has  no 
existence. 


First  thoracic  vertebra 


F'g-  V- 


Superior 
vena 
cava 


Left  internal  jugular  vein 
Lefc  subclavian  vein 
Left  innominate  vein 


Pulmonary  artery 
Ascending  aorta 


Pulmonic  opening 
Aortic  opening 
Left  auriculo-ventricular 
opening  (mitral  valve) 

Right  auriculo-ventricular 
opening  (tricuspid  valve) 
Cardiac  notch  of  the  border 
of  the  left  lung 

Absolute  cardiac  dulness 


Mammillary  line 


Axillary  line 


Fig.  46. 


Scapular  line 


Left  bronchus 


Left  interlobar  fissure 


Right  bronchus 


Middle  lobe  of 
right  lung 

Inferior  angle  of 
the  scapula 


Costophrenlc 
-  -__.     sinus  of 
pleura 


THE  CONTENTS  OF  THE  THORAX.  IOI 

lage.  The  highest  point  of  the  pleural  dome,  projected  upon  the  anterior  surface  of  the  body, 
is  situated  3.0  centimeters  above  the  anterior  extremity  of  the  first  rib. 

The  pleural  limits  are  those  situations  in  which  the  three  chief  portions  of  the  parietal  pleura 
become  continuous  with  each  other.  In  addition  to  the  dome  of  the  pleura,  containing  the  apex 
of  the  lung,  the  anterior  and  the  inferior  limits  of  the  pleura  are  of  importance  in  medical  exami- 
nation. The  anterior  pleural  limit  is  at  the  deepest  portion  of  the  costo-mediastinal  sinus  and 
corresponds  to  the  situation  in  which  the  costal  pleura  is  reflected  posteriorly  behind  the  sternum 
to  become  the  mediastinal  pleura.  The  inferior  pleural  limit  is  at  the  lowest  portion  of  the  costo- 
phrenic  sinus.  As  the  lung  almost  completely  fills  the  pleural  cavity,  the  pleural  limits  during 
inspiration  practically  coincide  with  the  anterior  and  inferior  pulmonary  margins.  Inferiorly 
the  pleural  cavity  extends  almost  to  the  origins  of  the  diaphragm.  In  figures  45  and  46  the 
pleural  limits  are  indicated  by  red  lines.  Upon  the  right  side  the  pleural  limit  commences  ante- 
riorly at  the  middle  of  the  sternoclavicular  articulation,  runs  toward  the  median  line,  which  it 
follows  downward  to  the  sixth  rib,  passes  outward  along  the  lower  border  of  the  sixth  rib,  crosses 
the  seventh  rib  in  the  mammary  line,  reaches  the  lower  border  of  the  ninth  rib  in  the  axillary 
line  and  the  eleventh  rib  in  the  scapular  line,  and  strikes  the  twelfth  rib  at  the  vertebral  column. 
[The  relations  of  the  pleura  to  the  twelfth  rib  are  of  importance  to  the  surgeon  especially  in  con- 
nection with  operations  on  the  kidney.  When  this  rib  is  not  abnormally  short,  the  pleural 
reflection  crosses  it  opposite  the  outer  border  of  the  erector  spinae  muscle,  hence  an  incision  may 
be  carried  deeply  as  far  as  the  angle  formed  by  the  twelfth  rib  and  the  outer  border  of  the  erector 
spinas  without  entering  the  pleura.  When,  however,  the  twelfth  rib  does  not  reach  the  outer 
border  of  the  erector  spinae,  an  incision  carried  upward  into  the  apex  of  the  angle  between  this 
muscle  and  the  eleventh  rib  is  almost  certain  to  wound  the  pleura.  Internal  to  the  outer  edge  of  the 
erector  spinae  the  pleural  reflection  lies  below  the  level  of  the  twelfth  rib  and  not  infrequently 
descends  as  far  as  the  transverse  process  of  the  first  lumbar  vertebra. — Cunningham's  "Text- 
book of  Anatomy."]  Upon  the  left  side  the  pleural  limit  extends  anteriorly  almost  to  the  median 
line,  and  passes  outward  at  the  level  of  the  fourth  rib,  so  that  at  the  seventh  costal  cartilage  it 
is  about  five  centimeters  distant  from  the  anterior  median  line  in  the  horizontal  direction.  The 
left  pleural  limit  then  follows  about  the  same  course  as  upon  the  right  side,  but  extends  a  trifle 
lower  in  the  axillary  line.  The  importance  of  these  relations  will  be  referred  to  in  the  descrip- 
tion of  the  pericardium.  The  pleural  limits  vary,  to  a  certain  extent,  in  different  individuals. 
When  one  lung  is  diseased,  it  is  frequently  observed  that  the  pleural  sac  containing  the  healthy 
lung  extends  beyond  the  normal  limits  as  a  result  of  the  vicarious  employment  of  this  lung  (Fig.  50). 

The  lowest  portion  of  the  costo-phrenic  sinus  is  not  completely  filled  by  the  lung,  even  in 
deep  inspiration.  As  a  matter  of  fact,  the  diaphragm  is  in  contact  with  the  inner  thoracic  wall 
in  this,  region  during  quiet  respiration.  When  there  is  an  abnormal  collection  of  fluid  in  the 
pleural  cavity,  the  diaphragm  may  be  pressed  downward  and  away  from  the  thoracic  wall;  if  the 
fluid  is  removed  by  tapping  (thoracocentesis),  however,  the  diaphragm  rises  again  and  comes 
in  contact  with  the  thoracic  wall  as  before.  In  this  manner  the  puncture  may  become  occluded 
and  hinder  the  withdrawal  of  the  fluid.  It  consequently  follows  that,  as  a  general  rule,  the  opera- 
tion should  not  be  employed  below  the  sixth  intercostal  space  in  the  posterior  axillary  line.  In 
the  back  the  puncture  may  be  made  as  low  down  as  the  ninth  intercostal  space.     The  absorp- 


102  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  47. — The  median  surface  of  the  right  lung.     From  plaster  cast  (His). 
Fig.  48. — The  median  surface  of  the  left  lung.     From  plaster  cast  (His). 

tion  of  inflammatory  exudates  is  made  possible  by  the  great  number  of  lymphatic  vessels  in  the 
pleura.  The  remains  of  such  exudates  are  frequently  found  at  postmortems  as  opacities  and 
thickenings  of  the  pleura  as  well  as  in  the  form  of  cicatricial  and  firm  adhesions  between  the 
parietal  pleura  and  the  surface  of  the  lung.     In  such  cases  the  lung  is  said  to  be  adherent. 

The  topographic  relations  of  the  pleural  cavities  and  of  the  lungs  to  the  abdominal  organs 
situated  immediately  beneath  the  diaphragm  are  of  great  importance.  These  relations  are 
described  upon  pages  128-133,  138,  and  139. 

The  Lungs. — The  apex  of  the  lung  fills  the  dome  of  the  pleura  and  consequently  extends 
above  the  superior  aperture  of  the  thorax  (Fig.  45,  Plates  11  and  13);  the  concave  base  rests 
upon  the  diaphragm.  The  costal  surface  of  the  lung  lies  against  the  inner  surfaces  of  the  ribs 
and  of  the  intercostal  spaces  (i.  e.,  against  the  costal  pleura) ;  the  diaphragmatic  surface  or  base 
is  in  contact  with  the  diaphragmatic  pleura.  The  third  or  mediastinal  surface  forms  the  boun- 
dary of  the  mediastinum  and  is  hollowed  out  to  accommodate  the  heart.  The  anterior  sharp 
margin  is  lodged  in  the  costo-mediastinal  sinus;  the  inferior  margin,  which  is  also  sharp,  is  directed 
toward  the  costo-phrenic  sinus.  The  posterior  convex  margin  is  surrounded  in  the  region  of  the 
angles  of  the  ribs  by  the  pulmonary  sulci  of  the  thorax  (Figs.  50  and  53).  At  the  root  of  the  lung 
(hilus  pulmonis)  upon  the  mediastinal  surface,  the  arteries  of  the  bronchi  enter,  and  the  veins 
leave  the  viscus  (Figs.  47  and  48). 

Each  lung  is  divided  into  two  lobes  by  a  deep  fissure  (incisura  interlobaris)  which  pursues 
an  almost  symmetrical  course  upon  the  two  sides.  It  passes  upward  and  backward  from  the 
hilus,  runs  forward  over  the  costal  surface  to  the  lower  pulmonary  margin,  crosses  the  base 
anteriorly,  and  ascends  to  the  hilus  along  the  mediastinal  surface.  In  the  left  lung  this  fissure 
separates  the  upper  from  the  lower  lobe.  In  the  right  lung  the  fissure  runs  more  directly  down- 
ward than  upon  the  left  side.  While  the  fissure  strikes  the  lower  margin  of  the  left  lung  about 
a  fingerbreadth  to  the  outer  side  of  its  anterior  extremity,  it  reaches  the  lower  margin  of  the  right 
lung  about  a  handbreadth  to  the  outer  side  of  the  corresponding  point.  In  the  right  lung  there 
is  a  second  fissure,  which  runs  from  the  hilus  over  the  mediastinal  surface,  crosses  the  anterior 
border  of  the  lung,  and  passes  horizontally  along  the  costal  surface  to  join  the  incisura  inter- 
lobaris. It  forms  the  upper  boundary  of  the  small  middle  lobe,  which  is  present  only  upon  the 
right  side  and  varies  greatly  in  its  development.  In  the  anterior  border  of  the  left  lung  there 
is  a  notch  (incisura  cardiaca)  the  concavity  of  which  is  directed  toward  the  median  line.  In  the 
hilus  the  branches  of  the  pulmonary  artery  are  the  highest  structures;  below  these  are  the  bronchi, 
with  the  exception  of  the  eparterial  bronchus  to  the  right  superior  lobe,  which  is  situated  higher 
up.     The  veins  are  partly  below  and  partly  in  front  of  the  bronchi  (Figs.  47  and  48). 

If  the  lungs  are  hardened  in  situ  and  the  neighboring  vessels  are  well  injected,  the  follow- 
ing grooves  may  also  be  noted :  the  grooves  for  the  superior  vena  cava  and  for  the  vena  azygos 
major  upon  the  right  lung;  the  grooves  for  the  left  subclavian  artery,  for  the  arch  of  the  aorta, 
and  for  the  descending  aorta  upon  the  left  lung. 

The  respiratory  changes  in  the  position  of  the  lung  are  most  distinctly  manifested  at  the 


Fi%-  47- 


Groove  for   superior  vena  cava 

Eparterial  bronchus 
Branches  of  pulmonary  artery 

Branches  of  pulmonary  veins 
Anterior  margin 

Mediastinal  surface 


Middle  lobe 


Diaphragmatic  surface 


Superior  lobe 


Hyparterial  bronchus 


Inferior  lobe 

Groove  for  vena  azygos  major 


Inferior  margin 


Apex  of  left  lung 


Interlobar  fissm-e 


Groove  for  descending  aorta   u 


Fig.  48. 
Groove  for  subclavian  artery 

Groove  for  arch  of  aorta 

Branches  of  pulmonary  artery 

Anterior  margin 

Branches  of  pulmonary  veins 


Mediastinal  surface  of 
superior  lobe 


Diaphragmatic  surface 


Inferior  margin 


THE   CONTENTS   OF  THE  THORAX.  103 

anterior  and  inferior  pulmonary  margins.  The  movement  of  the  anterior  margin  is  due  to  the 
anteroposterior  expansion  of  the  lung  (costal  breathing);  the  inferior  margin  moves  on  account 
of  the  vertical  expansion  of  the  lung  (diaphragmatic  breathing). 

During  expiration  the  anterior  margin  of  the  right  lung  extends  from  the  attachment  of  the 
second  costal  cartilage  along  the  right  sternal  margin  to  the  lower  border  of  the  fifth  rib.  The 
inferior  margin  is  situated  in  the  mammary  line  at  the  sixth  rib,  crosses  the  seventh  rib  in  the 
axillary  line  and  the  ninth  rib  in  the  scapular  line,  and  reaches  the  vertebral  column  at  the  level 
of  the  spinous  process  of  the  tenth  dorsal  vertebra.  The  anterior  border  of  the  left  lung  runs 
from  the  attachment  of  the  second  rib  to  the  upper  border  of  the  fourth  rib  somewhat  external 
to  the  left  sternal  margin.  From  the  fourth  intercostal  space  it  deviates  outward,  forming  the 
cardiac  notch  (incisura  cardiaca),  approaches  nearer  to  the  sternum  in  the  fifth  intercostal  space, 
and  becomes  continuous  with  the  inferior  pulmonary  margin  at  the  sixth  chondrocostal  articula- 
tion. From  this  point  the  inferior  pulmonary  margin  passes  outward  and  backward  as  upon 
the  right,  but  at  a  slightly  lower  level,  although  this  is  of  no  clinical  importance.  During  deep 
inspiration  the  anterior  margins  of  the  lungs  correspond  to  the  pleural  limits.  The  right  lung 
consequently  extends  somewhat  beyond  the  median  line,  while  the  left  one  barely  reaches  it. 
This  is  the  situation  in  which  the  two  lungs  are  in  closest  proximity,  being  separated  only  by 
a  very  narrow  portion  of  the  mediastinum.  The  inferior  margin  runs  obliquely  outward  and 
downward  from  the  sternal  line  at  the  lower  border  of  the  sixth  rib.  In  the  mammary  line  it 
is  at  the  level  of  the  upper  border  of  the  seventh  rib,  crosses  the  eighth  rib  in  the  axillary  line  and 
the  tenth  rib  in  the  scapular  line,  and  reaches  the  vertebral  column  at  the  level  of  the  spinous 
process  of  the  eleventh  dorsal  vertebra.  [The  lungs  in  the  midaxillary  line  are  probably  a  little 
lower  than  here  stated,  reaching  the  eighth  rib  in  expiration,  the  ninth  in  inspiration. — Ed.] 
The  posterior  boundary  between  the  superior  and  inferior  lobes  (incisura  interlobaris)  is  indi- 
cated upon  both  sides  of  the  chest  by  the  interscapular  line,  which  is  drawn  between  the  two 
inner  extremities  of  the  scapular  spines  with  the  arms  hanging  vertically  downward.  This  line 
also  indicates  the  level  of  the  hilus.  The  lungs  cannot  be  percussed  posteriorly  for  a  handbreadth 
to  either  side  of  the  vertebral  column,  since  the  long  muscles  of  the  back,  situated  in  the  dor- 
sal grooves  of  the  thorax,  hinder  the  transmission  of  auscultatory  phenomena.  Upon  the  left 
side  the  lateral  boundary  between  the  upper  and  the  lower  lobe  is  furnished  by  the  fifth  or  the 
sixth  rib;  anteriorly,  along  the  left  sternal  margin,  only  the  upper  lobe  is  present.  Upon  the 
right  side  the  middle  lobe  is  situated  anteriorly  and  anterolaterally  below  the  fourth  rib.  Even 
during  deep  inspiration  the  anterior  margin  of  the  left  lung  does  not  completely  fill  the  costo- 
mediastinal  sinus  in  the  region  of  the  cardiac  notch.  The  middle  and  the  inferior  lobes  rest 
upon  the  diaphragm  upon  the  right  side;  upon  the  left  side  only  the  inferior  lobe  is  in  relation 
with  the  diaphragm. 

If  the  diaphragm  is  pushed  upward  by  tympanites,  by  ascites,  or  by  abdominal  tumors,  the 
inferior  pulmonary  margin  will  be  found  at  a  higher  level  than  usual.  When  the  volume  of 
the  lung  becomes  greatly  increased,  as  in  emphysema,  the  inferior  pulmonary  margin  extends 
downward  beyond  the  normal  limit.  It  should  also  be  mentioned  that  the  inferior  margin  of 
the  lung  is  more  easily  determined  by  percussion  upon  the  right  side,  since  the  pulmonary  reson- 
ance passes  directly  into  the  hepatic  dulness,  while  upon  the  left  side  the  stomach  cannot  always 
be  differentiated  from  the  lung  by  typical  differences  in  the  percussion-note. 


104  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

PLATE   8. 

a,  A  dissection  of  the  mediastinum  seen  from  the  left;  almost  the  entire  left  half  of  the  thorax  has  been  removed 
and  the  left  lung  has  been  cut  away  at  its  root,  b,  The  mediastinum  seen  from  the  right.  Formalin  preparations  from 
a  child. 


THE   MEDIASTINUM. 

After  the  removal  of  the  lateral  thoracic  walls  and  of  the  lungs,  the  mediastinum  is  exposed 
from  both  sides  (see  Plate  8).  Upon  the  cut  surfaces  of  the  roots  of  the  lungs  may  be  seen  the 
divided  bronchi,  pulmonary  arteries,  and  pulmonary  veins,  which  pass  from  the  mediastinum 
into  the  lungs. 

The  contents  of  the  mediastinum  are  most  numerous  where  the  two  pleural  sacs  are  most 
widely  separated  in  the  median  line.  This  is  the  case  behind  the  sternum,  where  the  heart  is 
situated  within  the  pericardium  between  the  two  layers  of  mediastinal  pleura.  If  the  anterior 
thoracic  wall  is  also  removed  by  dividing  the  sternal  attachments  of  the  mediastinum,  and  if 
the  two  layers  of  mediastinal  pleura  are  slightly  reflected  backward,  the  pericardium  may  be 
easily  exposed.  If  the  pericardium  be  opened  and  the  heart  excised  it  will  at  once  be  appreciated 
that  the  two  pleural  cavities  and  the  lungs,  together  with  the  pericardium  and  heart,  occupy 
almost  the  entire  thoracic  space.  In  addition  to  the  heart  and  the  pericardium  the  contents 
of  the  mediastinum  include:  the  remains  of  the  thymus  gland,  a  large  portion  of  the  trachea  with 
its  bifurcation,  many  large  and  small  vessels  and  nerves,  the  esophagus,  lymphatic  vessels  includ- 
ing the  thoracic  duct,  and  many  important  lymphatic  glands.  These  structures  are  bound  together 
by  a  loose  connective  tissue  which  becomes  directly  continuous  with  the  loose  connective  tissue 
of  the  neck  and  furnishes  a  path  along  which  inflammations  (suppurations,  abscesses)  may 
easily  extend  from  the  neck  into  the  mediastinum  through  the  superior  aperture  of  the  thorax. 

The  chief  contents  of  the  mediastinum  may  be  seen  through  the  mediastinal  pleura  after 
the  removal  of  the  lungs,  if  the  membrane  retains  its  normal  transparency  and  has  not  become 
opaque  and  thickened  by  inflammation.  The  contents  become  still  more  distinct  if  the  two 
mediastinal  layers  are  removed. 

Upon  the  right  side  may  be  seen:  portions  of  the  heart  through  the  pericardium  (during 
childhood,  at  least),  the  superior  vena  cava,  the  phrenic  nerve  (upon  the  superior  vena  cava  and 
running  upon  the  pericardium  to  the  diaphragm),  the  comes  nervi  phrenici,  the  vena  azygos 
major  and  its  termination  in  the  superior  vena  cava,  the  right  intercostal  vessels,  the  esophagus, 
the  vagus  nerve,  the  right  sympathetic  and  splanchnic  nerves,  and  the  lymphatic  glands  at  the 
root  of  the  lung. 

Upon  the  left  side  the  visible  structures  are:  the  heart  with  the  left  phrenic  nerve,  the  comes 
nervi  phrenici,  the  descending  aorta,  the  left  subclavian  artery,  the  left  internal  mammary  artery, 
the  left  innominate  vein*  receiving  the  termination  of  the  vena  azygos  minor,f  the  vagus  nerve, 
the  left  sympathetic  nerve,  the  left  intercostal  vessels,  and  numerous  lymphatic  glands. 

In  children  the  thymus  gland  may  be  seen  from  either  side;  it  is  situated  in  front  of  and  above 
the  heart. 

*  Erroneously  designated  as  V.  Cava  sup.  in  the  plate. 

t  In  Plate  8,  a,  the  vena  azygos  minor  (vena  hemiazygos)  joins  a  very  large  superior  intercostal  vein  (see  page  1 1 7). 


Internal  mammary  a 
Internal  mammary  v 
Superior  vena  cava 
Thymus 
Lymphatic  gland 

Left  pulmonary  a 
Phrenic  nerve  and  comites  nervi  phrenici 
Left  superior  pulmonary  v 


Left 


Brfronchi 
pulmonary  v. 


Diaphragm 


PneuiflogasUrk  d. 


Sympathetic  n 


Vena  azygos  major 

Intercostal  vessels 

Esophagus 


Splanchnic  nerves 


PnoumqgaStric  n. 
S^jJHifBPftthirus 


Vena  azygr*  minor 
Intercostal  aa. 


Ksophagus 
Descending  aortudens 


Superior. vena  cava 
Thymus 

Ruiht  phrenic**    dex. 
McJiasimum 

Eparterial  lirnnchuateri&lis 

Right  pulmonary  artery 
Itypartcrial  Imnchus 
Right  pulmonary  veins 


Diaphragm 


\  dissection  of  the  m 


from  b^SJWSTSeVFfc 
divided  broneh^ 
into  the  lung^^, 


.a  oiltdtsqcaxZ' 

TH 
After  the  removal  of  the 
e^~ 


■  i;rn  Unnlnl 
V  ni;rnniBrn  li.m  ilnl 
raqu3 
ujrnxdT 

.1.  <ii;noii  lui|  fta  I 


in-jndii  i/i  in  ta&moo  box  svbo  _>umd'l 
isnoitifuq  nhdqirc  )KI 

iffonmU 


/n;uomluq  lohslai  JhJ 


widel\  separated  in  fh 

situal 

thor: 

the  I 

almo^ 


m-  myiiidqsiG 


rous  where  tl 
se  behind 

mediastim 
he  sternal  attachments 
H       ;:ted  bar         ] 

will 
ricardium  ana 
pericardium 
a  large  portion  of  thi  with 

The  esophagus,  lymphatic  vessels  includ- 
These  structures  are  bound  together 


of  th>  \ 

its  b;  iarge  an 

ing  tl  ad  many  iin 

^  a  '  tis^e  which  becomes  directjycontinuous  with  the  "loose  Conner 
of  li 

easih 


s  a  path  along^kfcTi  inflamm^i^s  (suppurations,  abscesses)  may 
.nW*lw*W*  thfi  mgrfiasfunim  through  thes»^rior  aperture  of  the  thoi 

4  the  mcdi^finum  ma;  \    ,       „  mting|»p|  Ura  after 

lun'"|U<i  '  ^lb|iint'  j;  r—  normal  transparency  and  has  not  become 
Ih^'  pi;  listinct  if  th< 


rrnmltenlbaM 
etffbnoid  Isiiji-UKvl  _ 


yTiliis  vir.niiriilmi  triaiX- 

iiidaoond  li;iioni;ir<H 

zniov  Yicnornluq  irfgifl- 


•.   heart  throug 

.  ^ — 


the 

root 

phrenic:. 
the  left  innom 

vmpathetic  m- 

the  lv 


__ 


oirnhnrMi?. 


— d  as  V. 

1 


A.  mamm.  int 
V.  mamm.  int. 
V.  cava  sup. 
Thymus 

Lvmphoglandulae    ■ 

A.  pulmonalis  sin. 
N.phrenicuset  Vasa  pericardiaco-phrenica 
V.  pulm.  sup.  sin.. 
Bronchi 

V.  pulm.  inf.  sin.  _. 


Diaphragma 


Tab.  8. 


N.  vagus 
N.  sympathicu8 

...V.  hemiazygos 
Aa.  intercostales 


Oesophagus 
Aorta  descendens 


A.  mamm.  int. 

V.  cava  sup. 

...Thymus 

N.  phrenicus  dex. 
Mediastinum 
Bronchus  eparterialis 

A.   pulm.  dex. 

Bronchi  hyparteriales 

--W.  pulmonale8  dex. 


Diaphragma 


THE   MEDIASTINUM. 


I05 


Our  chief  interest  in  the  mediastinum  is  naturally  directed  toward  the  heart,  the  methodical 
examination  of  which  in  the  living  by  percussion  and  auscultation  is  one  of  the  most  brilliant 
and  permanent  results  of  the  medical  art. 

The  study  of  the  position  of  the  heart  should  be  preceded  by  a  thorough  study  of  the  structure 
of  the  organ. 

The  Position  of  the  Heart. — For  our  purpose  I  will  designate  as  the  cardiac  axis  a  line 
drawn  from  the  apex  of  the  heart  to  the  root  of  the  aorta.  Take  an  ordinary  pointed  lead-pen- 
cil in  the  hand  and  assume  that  it  represents  the  cardiac  axis.     Hold  this  "axis"  vertically  over 


Esophagus 

Arch  of  aorta  with 
left  subclavian  a. 

Superior  lobe  of  left 
lung 

Pulmonary  artery 


Left  coronary  artery 

Pericardium 

Left  auriculo-ventri- 

cular  orifice 

Pericardial  cavity 

Left  ventricle 
Coronary  sinus 

Diaphragm 

Esophagus 

Inferior  vena  cava 

Costo-mediast  ina  1 
sinus 

Stomach 

Descending  aorta 


Right  pleural  cavity 


Superior  lobe  of  left 
lung 

Vena  azygos  major 

Point  of  bifurcation 

of  trachea 

Right  pulmonary 
artery 

Central  lobe  of  right 

lung 
Left  auricle 


Inferior  lobe  of  left 
lung 

Diaphragm 

Hepatic  vein  in 
inferior  vena  cava 


—  Liver 


Fig.  49. — A  view  of  the  dorsal  surface  of  a  frontal  section  of  the  thorax. 


the  middle  of  the  sternum  with  the  apex  downward,  under  the  supposition  that  the  right  (venous) 
heart  is  in  the  right  half  and  the  left  (arterial)  heart  is  in  the  left  half  of  the  body,  and  that  the 
intermediate  septum  is  exactly  in  the  median  line.  Now  consider  the  four  following  points  and 
carry  out  the  movements  of  the  axis  with  the  lead-pencil. 

1.  The  axis  is  not  placed  vertically,  but  obliquely,  so  that  the  apex  (point  of  lead-pencil) 
is  directed  to  the  left  and  the  base  (blunt  end  of  lead-pencil)  to  the  right. 

2.  The  axis,  and  consequently  the  entire  heart,  is  pushed  to  the  left,  so  that  the  median 
plane  of  the  body  does  not  correspond  to  the  median  plane  of  the  heart,  but  passes  through  this 


106  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

PLATE   9. 
An  anterior  view  of  the  heart;  the  parietal  pericardium  has  been  incised  and  reflected.     (Formalin  preparation.) 


organ  in  such  a  manner  that  two-thirds  of  the  heart  are  upon  the  left  side  of  the  body  and  one- 
third  is  upon  the  right. 

3.  The  apex  of  the  heart  touches  the  inner  surface  of  the  anterior  thoracic  wall  and  the 
base  approaches  the  vertebral  column.  The  anterior  surface  of  the  heart  is  consequently  also 
directed  upward  and  the  posterior  surface  rests  upon  the  diaphragm. 

Clearly  note  that  after  these  three  deviations  of  the  cardiac  axis  from  the  position  originally 
assumed,  the  cardiac  septum  is  still  at  right  angles  (but  not  in  the  sagittal  plane)  to  the  front- 
plane  of  the  body,  and  that  equal  portions  of  the  right  and  left  sides  of  the  heart  would  be  visible 
from  in  front. 

4.  The  heart  is  now  rotated  upon  its  axis  in  such  a  manner  that  the  greater  portion  of  the 
right  heart  is  directed  anteriorly  (and  superiorly)  while  the  greater  portion  of  the  left  heart  is 
situated  posteriorly  (and  inferiorly).  As  a  result  of  this  rotation  the  cardiac  septum  is  no  longer 
at  right  angles  to  the  frontal  plane,  but  lies  more  nearly  in  the  frontal  plane  itself,  as  is  best  shown 
in  frozen  sections  (Fig.  50). 

It  follows  that  the  auricles  at  the  base  of  the  heart  are  situated  superiorly  and  nearer  to 
the  dorsal  surface,  while  the  ventricles  are  nearer  to  the  thoracic  wall.  Injuries  of  the  ventricles 
are  consequently  comparatively  more  frequent  than  injuries  of  the  auricles.  As  a  further  con- 
sequence of  the  position  of  the  heart,  a  horizontal  penetrating  wound  may  enter  the  ventricle 
anteriorly  and  the  auricle  posteriorly.  Since  the  ventricles  are  in  contact  with  the  inner  sur- 
face of  the  thoracic  wall,  their  pulsations  may  be  felt  in  the  epigastrium  (beneath  the  xiphoid 
process),  when  there  is  marked  cardiac  hypertrophy.  The  right  ventricle  is  the  most  anterior 
portion  of  the  heart,  the  right  auricle  is  directed  toward  the  right,  the  left  ventricle  toward  the 
left,  and  the  left  auricle  is  quite  posterior  (Fig.  50).  In  looking  at  the  heart  from  in  front,  the 
following  structures  are  visible  (Plates  9  and  16) :  the  right  ventricle  with  the  origin  of  the  pul- 
monary artery  (comes  arteriosus),  a  narrow  zone  of  the  left  ventricle,  the  anterior  extremity  of 
the  left  auricular  appendix,  a  goodly  portion  of  the  right  auricle,  and  the  right  auricular  appendix. 
Each  auricular  appendix  is  situated  over  the  arterial  trunk  originating  from  the  opposite  ventricle. 

In  examining  an  excised  heart  the  various  structures  may  be  best  located  by  looking  first 
at  the  anterior  surface  of  the  viscus. 

At  the  inner  surface  of  the  anterior  thoracic  wall  the  largest  portion  of  the  heart  is  covered 
by  the  two,  anterior  pulmonary  margins.  As  they  are  air-containing  structures  they  partially 
mask  the  dull  note  obtained  by  percussion  over  this  portion  of  the  cardiac  area  (deep  cardiac 
dulness).  A  small  portion  of  the  heart  lies  directly  against  the  inner  surface  of  the  thoracic 
wall  and  is  not  covered  by  pulmonary  tissue;  over  this  area  the  trained  ear  recognizes  the  so- 
called  absolute  cardiac  dulness  upon  percussion.  It  is  clear  that  this  area  must  be  diminished 
when  the  lungs  are  distended  (by  emphysema,  for  example),  and  that  it  will  be  increased  when 
the  edges  of  the  lungs  are  drawn  or  pushed  to  one  side  (by  a  hypertrophied  heart,  for  example) 
(see  Fig.  50).     It  is  consequently  important  for  the  physician  to  be  acquainted  with  the  normal 


Right  innominate  v. 


Superior  vena  cava 


Ascending  aorta 


Right  auricle 


Conus  arteriosus 


Anterior  cardiac  v. 


Right  ventricle 


Left  innominate  v. 


Left  subclavian  a. 


Left  common  carotid  a. 


Left  pulmonary  a. 

Ligamentum  arteriosum 


Pericardium 
Pulmonary  a. 

Left  auricle 
Coronary  sulcus 


Great  cardiac  v. 
Left  ventricle 


Descending  branch  of  left 
coronary  a. 


Diaphragm 


e 


.«  atrtsiaiu-'.  JlaJ 


— — /  iietnmoani  JdaiM 


upward  ancLiil<l. 


•.£  alenimonnl 


■ 

in 


e/iij  snj/  lunaqu^ 


rfiii>«  -1      ^> 


Ji>l  lo  Ami  -■ 

mon 

the  left  auricular . 
Each  auricular  appen  j 

In  examining  / 

at  the  anteriopioKitg 

■. 
by  th 

dulnc. 


^ 

I  um 

,  .       I ta&  ,rf8,H 

he  heart  ..  > 
'                                      I 
'  the  au'-i         \  on- 

i 
\ 

1 


\ 


Tab  A 


Aorta  ascendens 


Auricula   dextra 


Conus  arteriosus 


V.  cordis  anterior 


Ventriculus  dexter 


V.  anonyma  sin. 

A.  subclavia  sin. 

A.  carotis  comm.  sin. 


Arcus  Aortae 


A.  pulmonalis  sin. 
L,igam.  arteriosum  (Botal 


Pericardium 
.A.  pulmonalis 

Auricula  sinistra 
Sulcus  coronarius 


Vena  cordis  magna 
Ventriculus  sin. 

Ram.  descendens 
a.  cor.  sin. 


Diaphragm  a 


THE   MEDIASTINUM. 


107 


extent  of  this  area  of  cardiac  dulness.     The  projection  of  the  entire  heart  upon  the  anterior 
thoracic  wall  is  also  worthy  of  note. 

The  projection  of  the  heart  upon  the  anterior  thoracic  wall  is  indicated  by  the  following 
lines  upon  the  external  surface: 

1.  The  inferior  cardiac  line  commences  in  the  fifth  left  intercostal  space  midway  between 
the  mammary  and  parasternal  lines  (at  the  cardiac  apex*),  passes  obliquely  upward  to  the  right, 
and  ends  at  the  lower  border  of  the  fifth  right  costal  cartilage,  two  centimeters  from  the  sternal 
margin. 

2.  The  right  cardiac  line  commences  at  the  termination  of  the  inferior  cardiac  line,  runs 
directly  upward  at  a  distance  of  two  centimeters  from  the  sternal  margin,  and  ends  at  the  upper 
border  of  the  third  right  rib. 


Arch  of  vertebra- 
Sympathetic  nerve 
Azygos  minor  vein- 
Inferior  lobe  of  left 
lung 
Descending  aorta 

Esophagus 
Left  vagus  nerve 


Left  auricle 

Superior  lobe  of  left 

lung 

Left  ventricle 

Root  of  the  aorta 

Pericardium 


Right  ventricle 


Sternum 


Latissimus  dorsi 
muscle 

Spinal  cord 
Azygos  major  vein 

W-/-Body  of  vertebra 


--  Serratus  magnus  m. 

Superior  lobe  of  right 
lung 

Pleural  cavity 


Opening  of  superior 

vena  cava  in  right 

auricle 

Superior  lobe  of  right 

lung 
Right  auricle 


-  Pectoralis  major  m. 

Internal  mammary 

artery 

"Internal  mammary 


FlG.  50._a  cross-section  of  the  thorax  at  the  level  of  the  nipples.     (The  right  lung  is  somewhat  enlarged  at  the  expense 

of  the  left  one.) 


3.  The  superior  cardiac  line  (not  indicating  any  sharp  cardiac  boundary)  commences  at 
the  termination  of  the  right  cardiac  line  and  runs  to  the  middle  of  the  second  left  intercostal 
space,  where  it  ends  at  a  point  three  centimeters  distant  from  the  sternal  margin. 

4.  The  left  cardiac  line  commences  at  the  termination  of  the  superior  cardiac  line  and  runs 
downward  to.  the  cardiac  apex. 

The  transverse  cardiac  line  should  also  be  borne  in  mind;  it  commences  where  the  inferior 
cardiac  line  crosses  the  lower  border  of  the  sixth  right  costal  cartilage  and  ends  at  the  point  of 

*  The  cardiac  apex,  as  well  as  the  apex-beat,  is  higher  in  children,  sometimes  being  situated  in  the  fourth  intercostal 
space;  it  is  lower  in  the  aged,  where  it  may  be  found  in  the  sixth  intercostal  space. 


IC>8  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

intersection  of  the  left  cardiac  line  with  the  upper  border  of  the  third  left  rib.  The  auriculoven- 
tricular  orifices  are  situated  beneath  this  line.  The  area  of  absolute  cardiac  dulness  (colored 
black  in  Fig.  45)  is  bounded  upon  the  right  by  a  line  drawn  from  the  lower  border  of  the  sternal 
attachment  of  the  fourth  left  costal  cartilage  along  the  left  sternal  margin  to  the  lower  border 
of  the  seventh  left  costal  cartilage ;  it  is  bounded  upon  the  left  by  a  line  commencing  at  the  origin 
of  the  right  boundary  and  extending  to  the  cardiac  apex.  The  area  of  absolute  cardiac  dulness 
has  no  sharp  inferior  limit  on  account  of  the  neighboring  hepatic  dulness. 

The  auriculoventricular  orifices  are  situated  beneath  the  transverse  cardiac  line.  The  tri- 
cuspid orifice  is  between  the  insertions  of  the  left  fifth  and  the  right  sixth  rib  behind  the  lower 
end  of  the  sternum;  the  mitral  orifice  is  in  the  upper  third  of  the  transverse  cardiac  line.  The 
pulmonary  orifice  is  covered  by  the  sternal  end  of  the  third  left  costal  cartilage ;  the  aortic  orifice 
is  posterior  to  the  pulmonary  orifice  and  is  behind  the  sternum  at  the  level  of  the  third  intercostal 
space. 

For  physical  reasons  the  areas  for  auscultating  these  valves  do  not  correspond  accurately 
with  the  projections  of  the  valves  upon  the  anterior  thoracic  wall. 

Pericardium. — The  heart  does  not  lie  exposed  within  the  mediastinum,  but  is  situated 
within  the  pericardium.  The  pericardium  with  its  contents  is  placed  between  the  two  layers  of 
mediastinal  pleura  in  such  a  way  that  it  projects  more  toward  the  left  than  toward  the  right 
pleural  cavity.  It  will  be  remembered  that  the  left  pleural  cavity  (and  the  left  lung)  is  smaller 
than  the  right  one*  and  that  the  mediastinal  surface  of  the  left  lung  is  more  concave  than  that 
of  the  right  lung.  That  portion  of  the  mediastinal  pleura  which  is  reflected  over  the  pericardium 
is  also  known  as  the  pleura  pericardiaca.  Together  with  the  pericardium  it  forms  a  thin  lamella 
which  may  be  lifted  up  from  the  heart,  and  which  is  not  so  thick,  at  least  during  childhood,  but 
that  the  individual  portions  of  the  heart  may  be  seen  and  felt  through  it.  In  making  an  autopsy 
the  pericardial  pleura  and  the  pericardium  are  usually  described  as  "the  pericardium." 

The  intimate  relation  of  the  pericardium  and  pleura  in  this  situation  is  of  great  practical 
importance,  since  inflammations  of  the  pericardium  may  easily  extend  to  the  pleura  and,  upon 
the  other  hand,  a  pleurisy  may  be  followed  by  a  pericarditis.  The  pleural  cavities  and  the  lungs 
are  separated  from  the  pericardial  cavity  and  the  heart  by  only  a  thin  septum.  It  will  therefore 
be  readily  understood  that  diseases  of  the  lung  (such  as  tuberculosis)  may  extend  to  the  pleura 
and  to  the  pericardium.  The  septum  may  even  be  perforated,  so  that  pus  from  the  pleural 
cavity  (in  pyothorax)  or  air  from  an  opened  pulmonary  cavity  may  enter  into  the  pericardium 
(pyopericardium,  pneumopericardium). 

The  lower  surface  of  the  pericardium  is  firmly  attached  to  the  diaphragm  (see  page  99). 

In  the  pericardium,  as  in  the  pleura,  we  differentiate  a  parietal  layer  (usually  called  simply 
"the  pericardium")  and  a  visceral  layer.  Above  the  base  of  the  heart  the  parietal  layer  is  re- 
flected upon  the  great  vessels,  so  that  the  superior  vena  cava,  as  well  as  a  large  portion  of  the 
aorta  and  of  the  pulmonary  artery,  are  situated  within  the  pericardium  and  are  covered  by  the 
visceral  layer.  The  visceral  pericardium  is  as  firmly  adherent  to  the  heart  as  is  the  visceral 
pleura  to  the  lung.     The  visceral  pericardium  in  this  situation  is  also  known  as  the  epipericardium. 

Within  the  pericardium,  the  ascending  aorta  and  the  pulmonary  artery  are  firmly  united 
by  connective  tissue  and  surrounded  by  a  common  sheath  of  visceral  pericardium.     The  index- 


THE   MEDIASTINUM. 


109 


finger  may  consequently  be  passed  behind  both  of  these  structures  into  the  sinus  transversus 
pericardii,  which  is  bounded  anteriorly  by  the  posterior  surface  of  the  pulmonary  artery  and  of 
the  aorta,  and  posteriorly  by  the  anterior  wall  of  the  auricles  (consisting  chiefly  of  the  left  auricle). 
The  aorta  and  the  pulmonary  artery  are  the  only  vessels  around  which  the  finger  may  be  passed 
after  the  pericardial  sac  has  been  opened.  None  of  the  other  vessels  possess  a  complete  covering 
of  visceral  pericardium  at  their  cardiac  extremities,  but  they  are  all  more  or  less  distinctly  visible 


Orifice  of  azygos  major  vein- 


Superior  vena  cava 


Lung 


Orifice  of  right  superior 
pulmonary  vein 


Orifice  of  right  inferior 
pulmonary  vein 

Esophagus 


Orifice  of  inferior  vena  cava 


Innominate  artery 
Arch  of  aorta 

Sinus  transversus  pericardii 
Ascending  aorta 

K|^^B Pulmonary  artery 

,  Bronchi 

-  Orifice  of  left  superior 
pulmonary  vein 

Orifice  of  left  inferior 
pulmonary  vein 

_.  Left  vagus  nerve 


Diaphragm 


Fig   si—  The  dorsal  half  of  a  frontal  section  of  the  pericardium  with  the  large  vessels.     An  opening  has  been  made 
in  the  posterior  wall  of  the  pericardium  so  that  the  esophagus  is  exposed.     (Formalin  preparation.) 

in  the  pericardium.  From  in  front,  the  superior  vena  cava  may  be  seen  high  up  and  to  the  right 
alongside  of  the  aorta;  the  inferior  vena  cava  is  visible  when  the  heart  is  pushed  upward  and  to 
the  left;  the  left  pulmonary  veins  are  exposed  by  holding  the  heart  upward  and  to  the  right  by 
means  of  its  apex;  the  right  pulmonary  veins  are  scarcely  to  be  seen  because  they  are  covered 
by  the  right  auricle.  By  moving  the  heart  about  in  this  manner  it  will  be  seen  that  it  is  suspended 
in  the  pericardial  cavity  by  the  great  vessels.     The  removal  of  the  heart  may  consequently  be 


no 


TOPOGRAPHIC    AND    APPLIED    ANATOMY. 


accomplished  by  simply  dividing  all  of  the  large  vessels.  When  this  is  done,  the  posterior  wall 
of  the  pericardium  with  the  lumina  of  the  blood-vessels  is  distinctly  visible  (Fig.  51).  The 
posterior  pericardial  wall  possesses  no  reflection  of  mediastinal  pleura,  but  is  directly  in  contact 
with  the  loose  connective  tissue  of  that  portion  of  the  mediastinal  space  which  is  situated  behind 
the  heart  (see  Fig.  50).  In  this  location  the  structure  nearest  to  the  heart  is  the  esophagus,  which 
often  forms  a  slight  prominence  in  the  pericardial  sac,  and  which  may  always  be  palpated  through 
the  pericardium  in  the  dead  subject  and  easily  exposed  (Fig.  51). 


Thyroid  gland 


Left  jugular  vein 
Left  subclavian  vein- 

Left  innominate  vein 


Trachea 

"'  Clavicle 

Subclavian  muscle 

Lymphatic  gland 

Right  innominate  v. 

Innominate  artery 


Pericardium 


Diaphragm 


Broad  ligament  of  liver 


Fig.  52. — The  anterior  thoracic  wall  with  the  pericardium  and  the  diaphragm  seen  from  within.  The  dashed 
and  dotted  lines  represent  the  anterior  pleural  limits;  between  them,  at  the  level  of  the  fifth  left  costal  cartilage,  is  the 
site  for  aspiration  of  the  pericardial  cavity.     (Formalin  preparation.) 


It  is  at  this  point  that  the  deposition  of  a  considerable  quantity  of  pericardial  exudate  may 
press  upon  the  esophagus  and  produce  dysphagia.  By  irritation  of  the  vagus  nerve  (Fig.  51) 
pericarditis  in  this  situation  may  also  cause  vomiting,  hiccough,  and  paralysis  of  the  vocal  cords. 
This  practical  and  important  relation  will  be  referred  to  again  when  we  discuss  the  esophagus 
in  detail. 


THE   MEDIASTINUM. 


Ill 


Not  less  important  is  the  fact  that  a  comparatively  small  area  of  the  pericardium  is  in  im- 
mediate contact  anteriorly  with  the  inner  surface  of  the  thoracic  wall.  This  place  is  situated 
where  the  two  anterior  pleural  limits  diverge  close  to  the  left  sternal  border  from  the  fifth  to  the 
seventh  costal  cartilage.  In  withdrawing  fluid  from  the  pericardial  cavity  it  is  best  to  make 
the  puncture  in  the  fifth  intercostal  space  close  to  the  sternal  margin.  If  the  puncture  is  made 
further  to  the  left,  there  is  danger  of  injuring  the  left  pleural  sac. 

A  knowledge  of  the  relation  of  the  pericardium  to  the  thoracic  wall  is  also  necessary  when 
it  is  desired  to  open  retrosternal  abscesses  or  to  remove  tumors  from  behind  the  sternum  by  a 
partial  resection  of  this  bone,  since  the  pleural  and  pericardial  cavities  should  not  be  clumsily 
nor  unnecessarily  opened. 


Erector  spina?  muscle      Trapezius  muscle 


Scapula- 
Spinal  cord 
Pleural  cavity- 

Subscapular 

vessels. 


Bifurcation  of 

trachea 

Azygos  major  vein 

Right  lung 

Superior  vena  cava 

Sinus  transversus 

pericardii 

Ascending  aorta 


Deltoid  muscle 


Subscapularis 

-Descending  aorta 

Serratus  magnus 

.  -Esophagus 

Left  pulmonary 

artery 

_Left  lung 
—Lymphatic  glands 


Pectoralis  minor 
Pectoralis  major 


Internal  mammary  artery  with  vein 
Fig.  53.— A  cross-section  of  the  thorax  at   the   level   of   the  tracheal   bifurcation   (frozen  section).      The   left  lung 
was  diseased  at  its  apex  and  diminished  in  size  as  a  whole;  the  right  lung  was  correspondingly  enlarged. 


Since  the  mediastinum  is  not  a  rigid  partition  between  the  two  pleural  cavities,  but  rather 
a  movable  and  elastic  septum,  as  is  necessary  for  costal  breathing,  it  is  clear  that  when  a  pleural 
cavity  is  distended  by  abnormal  contents  (pyothorax,  pneumothorax)  or  when  one  lung  requires 
more  space  than  normally  belongs  to  it,  the  mediastinum  together  with  the  heart  will  be  pushed 
toward  the  opposite  side.'  This  may  be  recognized  by  the  physician  by  the  displacement  of  the 
cardiac  dulness.  A  left-sided  pleural  exudate,  for  example,  may  push  the  right  border  of  the 
normal  cardiac  dulness  far  beyond  the  right  margin  of  the  sternum.  If  the  lung  becomes  con- 
tracted, as  in  cirrhosis,  and  adherent  to  the  mediastinal  pleura,  the  mediastinum  will  be  drawn 
toward  the  same  side,  and  the  opposite  lung,  when  healthy,  may  undergo  a  compensatory  enlarge- 


112  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE    10. 

The  vessels  and  nerves  of  the  mediastinum  and  their  relation  to  the  cervical  viscera.  The  first  illustration  repre- 
sents the  structures  as  seen  from  the  left,  while  the  second  shows  them  as  seen  from  the  right.     (Formalin  preparation.) 

merit.  In  this  manner  the  cardiac  dulness  may  be  displaced  to  the  left  beyond  the  mammary 
line,  by  a  contraction  of  the  left  lung  and  of  its  pleural  cavity. 

The  Thymus  Gland. — Immediately  behind  the  sternum,  enclosed  between  the  two  layers 
of  the  mediastinal  pleura  and  extending  upward  toward  the  neck,  are  found  the  remains  of  the 
thymus  gland,  which  usually  have  undergone  fatty  degeneration,  but  which  still  retain  their 
original  bilobed  structure.  During  childhood  the  grayish-red  gland  may  be  seen  glistening 
beneath  the  pleura.  If  the  layers  of  the  mediastinal  pleura  are  dissected  back,  we  penetrate 
further  into  the  mediastinal  space  and  readily  expose  the  superior  vena  cava  with  the  superim- 
posed right  phrenic  nerve  (see  Plate  10).  The  superior  vena  cava  produces  a  deep  groove  upon 
the  median  surface  of  the  right  pulmonary  apex  (see  Fig.  47).  It  arises  at  the  level  of  the  sternal 
insertion  of  the  first  rib  upon  the  right  by  the  junction  of  the  longer  left  with  the  shorter  right 
innominate  vein,  and  is  easily  injured  by  a  penetrating  wound  close  to  the  right  sternal  margin. 
Each  innominate  vein  is  formed  behind  the  corresponding  sterno-clavicular  articulation  by  the 
union  of  the  internal  jugular  with  the  subclavian  vein.  The  left  innominate  vein  does  not  pro- 
ject above  the  superior  margin  of  the  sternum  (see  page  68) ;  it  receives  the  middle  thyroid  veins. 
The  vena  azygos  major  (see  page  116,  Figs.  49  and  51,  and  Plates  7  and  8)  passes  from  the  ver- 
tebral column  over  the  right  bronchus  to  empty  into  the  superior  vena  cava  posteriorly  just 
before  this  vessel  enters  the  pericardium. 

The  Ascending  Aorta. — The  ascending  aorta  is  situated  within  the  pericardium  to  the  left 
of  the  superior  vena  cava;  still  further  to  the  left  is  the  pulmonary  artery.  To  avoid  confusing 
the  aorta  with  the  pulmonary  artery,  a  common  mistake  of  the  tyro,  it  should  be  clearly  noted 
that  the  commencement  of  the  aorta  crosses  behind  the  pulmonary  artery,  so  that  the  aorta, 
although  arising  from  the  left  ventricle,  is  situated  to  the  right  of  the  pulmonary  artery  and  is  the 
middle  vessel  of  the  three  great  trunks  at  the  base  of  the  heart.  Aneurysms  of  the  ascending 
aorta  frequently  rupture  into  the  pericardial  cavity,  producing  a  fatal  hemorrhage.  This  vessel 
is  about  six  centimeters  in  length;  it  runs  backward  and  downward  toward  the  left  and  then 
forward,  upward,  and  to  the  right  [by  English  authors  the  ascending  aorta  is  described  as  running 
forward,  upward,  and  to  the  right — Ed.],  so  that  it  gradually  approaches  the  inner  surface  of 
the  thoracic  wall.  The  origin  of  the  aorta  is  at  the  level  of  the  upper  border  of  the  sternal  attach- 
ment of  the  third  left  costal  cartilage,  six  centimeters  behind  the  sternum;  at  the  level  of  the 
first  intercostal  space  it  is,  however,  only  two  centimeters  behind  the  sternum  [i.  e.,  behind  the 
right  margin  of  the  sternum — Ed.].  The  right  convex  border  of  the  aorta  extends  to  the  right 
sternal  margin.  It  is  in  this  situation  that  aneurysms  of  the  ascending  aorta  are  particularly 
prone  to  press  forward  the  anterior  thoracic  wall  and  rupture  externally;  they  may  also  occasion- 
ally perforate  into  the  right  pleural  cavity.  Such  an  aneurysm  may  press  upon  the  superior 
vena  cava  on  the  right  and  cause  symptoms  of  venous  stasis  in  the  region  drained  by  this  great 
trunk ;  it  may  press  upon  the  pulmonary  artery  on  the  left  and  lead  to  a  hypertrophy  of  the  right 
ventricle  (Plate  9).     Rupture  into  both  of  these  vessels  has  also  been  observed.     The  most  im- 


Tah.JO 


Larynx 


Isthmus  of  thyroiil  gland 
Left  common  carotid  a. 
v-   th»RWle  th^cWi  V. 

Left  innominate  v. 
Inferior  laryngeal  n. 

Left  subclavian  a. 


t.eft  pneumogastric  n 
Left  phrenic  n 
Vena  comes  nervi  phrenid 

Ascending  aorta 


Pulmonary  a. 


Left  inferior  pulmonary  v 


Descending  aorta 


Esophagus 
Trachea 

Inferior  laryngeal  n. 

ftrtoiBto|m 

Left  pulmonary  a. 
Loft  Rupurior  pul- 


Hyparterial 
bronchi 


Kparterial 

Right  pulmon 

ary  a. 


10 


•fnyfo^lil2jhyreoidea 

Right  pneumogastric  n. 

Right  common  caroti.l  a. 

Right  inferior  laryngeal  n. 

Esophagus 

A,  subclavja  dex. 

Right  subclavian  a. 

Right  innominate  v. 

Trachral  rami 
Left  innominate  r. 
Trachea 

Surxiior  vena  cava 
Right  phrenic  n. 
Vena  aaygos  major 

Ascending  aorta 

Pericardium'"11 
Right  superior  pulmon- 
ary v. 


Left  pneumogastric  n. 


Pu1m*httrP\fcnali8 

Krone hi  hvp- 
H,IaSS&!rn,hi 

\'     aulrn-  dex.  inf. 
Right  inferior  pulmonary  v. 

^        a.  descendens 
Descending  aorta 

Intercostal  arterioles 


Right  pneumogastric  n. 


112 


I'OMY. 


alia  j 


basis 

i  *urunnq  iri»i>l 

.  oommoo  irts'iH 


unioani  JnjMM 

Each  »;;  \ 

iv jp  BB3V  loraqug 

union  of  the 

q  iriux  - 

i 


|  git era 


____L_Lti¥wld  tin 


bub  |.i.>i/rtt  l»  puaam 


biur/rf)  -.Ibl'il/ 


rfijKfejEHomiromi  >teJ 
UttrftfUatae/ 

from  the  ver- 


first  intr 
right  m; 

trunk;  it  n 
ventricle  fl 


dium  to  th 
avoid  confusing 
4(  Wi&'mioq  *ri*nin*aed 
so  that  the  to 


—cOjipriqoeH 


n  onJexaorau'"' 


Tab.  10. 


Larynx 


Isthmus  glandulae  thvr. 
A.  carotis  comm.  sin. 

V.  thyreoidea  ima 

V.  anonyma  sin. 
N.  laryngeus  inferior 

A.  subclavia  sin. 


N.  vagus  sin. 

N.  phrenicus  sin. 

V.  pericardiaco-phrenica 

Aorta  ascendens 


A.  pulmonal 


V.  pulmonalis  sin.  inf 


Aorta  descendens 


Oesophagus 


N.  vagus  sin 


Oesophagus 

Trachea 
Arcus  aortae 

N.  laryngeus 
inf. 

Pericardium 

A.  pulm.  sin. 
V.  pulm.  sin. 

sup. 
^Bronchi  hyp- 
arteriales 

Bronchus 
eparterialis 

A.  pulm.  dex. ' 


Glandula  thyreoidea 
N.  vagus  dexter 

A.  carotis  com.  dex. 

N.  larvng.  inf.  dex. 

Oesophagus 

A.  subclavia  dex, 

V.  anonyma  dex. 
Rami  tracheales 
V.  anonyma  sin. 
Trachea 

V.  cava  sup. 

N.  phrenicus  dex. 

V.  azygos 


Aorta  ascendens 

.Pericardium 

-  -V.  pulm.  dex.  sup. 


A.  pulmonalis 


Bronchi  hyp- 
art  eri  ales 
V.  pulm.  dex.  inf. 


Aa.  intercostales 


N.  vagus  dex 


THE  MEDIASTINUM.  113 

portant  branches  of  the  ascending  aorta  are  the  coronary  arteries,  which  arise  from  the  right  and 
left  aortic  sinuses  (sinuses  of  Valsalva).  The  right  coronary  artery  runs  backward  in  the  right 
coronary  groove  (between  the  auricle  and  ventricle),  and  then  downward  in  the  posterior  inter- 
ventricular groove  to  the  cardiac  apex.  The  left  coronary  artery  immediately  divides  into  an 
anterior  branch,  which  passes  downward  in  the  anterior  interventricular  groove,  and  a  transverse 
branch  which  runs  in  the  left  coronary  groove. 

The  Arch  of  the  Aorta. — The  arch  of  the  aorta  commences  at  the  origin  of  the  innominate 
artery  and  extends  to  the  left  side  of  the  body  of  the  third  or  fourth  dorsal  vertebra,  where  it  be- 
comes the  descending  aorta.  It  runs  over  the  root  of  the  left  lung  in  an  approximately  sagittal 
direction  (Fig.  53)  and,  in  contrast  to  the  ascending  aorta,  continually  becomes  more  distant 
from  the  anterior  thoracic  wall.  The  left  innominate  vein  lies  in  front  of  the  upper  convex  mar- 
gin of  the  aortic  arch  and  passes  obliquely  downward  and  to  the  right  in  front  of  the  origins  of 
the  three  main  branches  of  the  aorta, — the  innominate,  the  left  common  carotid,  and  the  left 
subclavian  arteries.  The  aortic  arch  does  not  extend  upward  beyond  the  sternal  attachment 
of  the  first  rib ;  its  highest  point  is  situated  at  about  the  level  of  the  center  of  the  manubrium. 
From  the  course  of  the  aortic  arch  it  follows  that  the  innominate  artery  is  nearest  to  the  anterior 
thoracic  wall,  the  left  common  carotid  is  further  removed,  and  the  left  subclavian  is  the  most 
distant  of  the  three  vessels.  The  left  subclavian  artery  projects  into  the  upper  portion  of  'the 
dome  of  the  pleura  and  produces  the  subclavian  groove  upon  the  apex  of  the  left  lung  (see  page 
102  and  Fig.  48).  The  left  inferior  laryngeal  nerve,  a  branch  of  the  left  pneumogastric,  passes 
backward  and  upward  around  the  aortic  arch  (see  page  68  and  Plate  10).  It  is  the  motor  nerve 
of  the  larynx,  and  is  often  compressed  by  aortic  aneurysms,  producing  one  of  the  first  symptoms 
of  this  affection— a  paralysis  of  the  left  vocal  cord.  Aneurysms  of  the  aortic  arch  may  produce: 
venous  stasis  of  the  head,  of  the  neck,  and  of  the  left  upper  extremity  by  pressing  upon  the  left 
innominate  vein  or  its  tributaries  (Plate  9);  deficient  ventilation  of  the  lungs  (dyspnea)  by  pres- 
sure upon  the  trachea,  or  only  of  the  left  lung  by  pressure  upon  the  left  bronchus  and  the  left 
pulmonary  artery;  paralysis  of  the  left  vocal  cord  by  pressure  upon  the  left  inferior  laryngeal 
nerve,  the  motor  nerve  of  the  muscles  of  the  interior  of  the  larynx;  and  dysphagia,  from  pressure 
upon  the  left  pneumogastric  nerve  and  upon  the  esophagus.  Such  aneurysms  may  rupture  (Plate 
7)  into  the  trachea  and  left  bronchus  (hemoptysis)  or,  if  the  aneurysm  is  situated  posteriorly, 
into  the  esophagus  (hematemesis).  The  comprehension  of  all  the  preceding  possibilities  will 
be  facilitated  by  a  careful  study  of  Plate  10. 

The  Thoracic  Descending  Aorta.— The  thoracic  descending  aorta  extends  from  the  left 
side  of  the  body  of  the  third  or  fourth  dorsal  vertebra  to  the  aortic  opening  in  the  diaphragm,  in 
which  situation  it  has  usually  reached  the  median  line.  After  the  removal  or  displacement 
of  the  left  lung  the  aorta  mav  consequently  be  seen  through  the  mediastinal  pleura  at  the  left 
side  of  the  vertebral  column  (Plates  8,  a,  and  17).  The  esophagus  is  at  first  upon  the  right  side 
and  then  in  front  of  the  vessel  (Fig.  54)  with  which  it  is  united  by  loose  connective  tissue.  The 
intercostal  arteries  arise  from  the  posterior  surface  of  the  aorta  (see  page  96);  there  are  nine 
pairs  for  the  lower  nine  intercostal  spaces  and  one  pair  for  the  lower  border  of  the  twelfth  rib. 
In  addition  to  these  vessels,  there  are  many  small  visceral  branches  which  are  not  particularly 

8 


114  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

Fig.  54. — The  pharynx,  esophagus,  trachea,  and  aorta  seen  from  behind. 

important  from  an  operative  standpoint ;  these  are  the  bronchial,  the  esophageal,  the  pericardiac, 
the  mediastinal,  and  the  diaphragmatic. 

Large  aneurysms  of  the  descending  aorta  occasionally  erode  the  vertebras  and  adjacent 
ribs  and  appear  in  the  back  alongside  of  the  vertebral  column,  where  they  may  simulate  abscesses. 
In  such  cases  disagreeable  symptoms  are  produced  by  pressure  upon  the  intercostal  nerves  and 
upon  the  spinal  cord. 

The  Pulmonary  Artery. — The  pulmonary  artery  is  united  with  the  ascending  aorta  by 
connective  tissue  (see  page  108)  and  is  situated  almost  entirely  within  the  pericardium.  The 
ascending  aorta  is  upon  the  right  side  of  the  vessel.  The  pulmonary  artery  extends  from  the 
sternal  insertion  of  the  third  left  costal  cartilage  to  that  of  the  second,  and  is  consequently  most 
easily  reached  through  the  second  left  intercostal  space.  The  vessel,  at  its  origin,  is  only  two 
centimeters  distant  from  the  anterior  thoracic  wall;  it  runs  backward,  upward,  and  somewhat 
toward  the  left  and,  after  a  course  of  about  five  centimeters,  divides  outside  of  the  pericardium 
into  a  right  and  a  left  branch.  From  the  bifurcation,  or  from  the  commencement  of  the  left 
branch,  the  ligamentum  arteriosum  passes  to  the  concavity  of  the  aortic  arch.  This  structure 
is  fhe  remains  of  the  fetal  ductus  Botalli,  which  may  remain  patulous  in  rare  cases.  The  right 
branch  of  the  pulmonary  artery  runs  transversely  behind  the  ascending  aorta  and  the  superior 
vena  cava  to  the  hilus  of  the  right  lung;  the  left  branch  is  shorter  and  passes  in  front  of  the  de- 
scending aorta  to  the  left  lung. 

The  pulmonary  veins  (double  on  both  sides)  are  designated  as  superior  and  inferior,  the 
superior  vein  lying  also  more  anteriorly  and  the  inferior  vein  more  posteriorly.  The  right  superior 
pulmonary  vein  is  situated  behind  the  termination  of  the  superior  vena  cava  in  the  right  auricle; 
behind  this  vein  are  the  right  pulmonary  artery  and  the  right  bronchus.  The  right  inferior 
pulmonary  vein  lies  between  the  right  bronchus  and  the  termination  of  the  inferior  vena  cava 
in  the  right  auricle.  The  superior  left  pulmonary  vein  is  found  in  front  of  the  left  bronchus 
and  the  inferior  left  pulmonary  vein  is  below  the  left  bronchus. 

The  Trachea. — The  portion  of  the  trachea  situated  within  the  mediastinum — i.  e.,  the  thor- 
acic portion,  in  contradistinction  to  the  cervical  portion  (see  page  51) — corresponds  to  that  part 
of  the  trachea  which  extends  from  the  lower  border  of  the  last  cervical  vertebra  to  the  fourth 
dorsal  vertebra.  In  the  latter  situation  the  trachea  divides  into  the  right  and  left  bronchus.  The 
point  of  bifurcation,  when  projected  upon  the  posterior  thoracic  wall,  is  situated  in  the  line 
connecting  the  inner  extremities  of  the  scapular  spines  (interscapular  line);  this  point  corre- 
sponds to  the  level  of  the  spinous  processes  of  the  third  dorsal  vertebra,  in  which  situation  we 
auscult  respiratory  murmurs  originating  within  the  trachea.  Corresponding  with  the  greater 
volume  of  the  right  lung,  the  right  bronchus  is  larger  than  the  left  and  runs  more  in  the  direction 
of  the  trachea ;  it  is  consequently  more  vertical  than  the  left  bronchus.  For  these  reasons  foreign, 
bodies  in  the  trachea  pass  more  readily  into  the  right  than  into  the  left  bronchus.  The  aortic 
arch  runs  backward  over  the  left  bronchus  (Plate  7);  the  vena  azygos  major  passes  from  behind 
forward  over  the  right  bronchus  to  empty  into  the  superior  vena  cava  (Plates  7  and  8,  b).  The 
lower  end  of  the  trachea  is  behind  the  aortic  arch;   above  the  arch,  the  trachea  is  found  in  the 


F'g-  54- 


Left  common   carotid  artery 


Esophagus \ 
Left  subclavian  artery 

Arch  of  aorta 

Left  superior   pulmonary  vein 
Left  pulmonary  artery  . 
Left  bronchus  . 


Left  inferior  pulmonary  vein 
Thoracic  aorta 


Pericardium  „ 


Cardiac  end  of  stomach 


Epiglottis 


Pharynx 

Right  common  carotid  artery 

Thyroid  gland 

Right  subclavian  artery 

Trachea 

Superior  vena  cava 

Vena  azygos  major 

Right  superior  pulmonary  vein 

Right  bronchus 

Eparterial  bronchus 

Lymphatic  glands 
Right  pulmonary  artery 
Hyparterial  bronchi 

Right  inferior  pulmonary  vein 
Intercostal  arteries 

Inferior  vena  cava 
Diaphragm 


THE   MEDIASTINUM.  II(- 

angle  between  the  innominate  and  left  carotid  arteries.  The  esophagus  runs  behind  the  trachea 
and  is  displaced  somewhat  to  the  left  (Fig.  54). 

The  angle  of  the  tracheal  bifurcation  is  filled  by  a  varying  number  (twenty  to  thirty)  of 
lymphatic  glands  which  follow  the  bronchi  as  far  as  the  hilus  of  the  lung  and  are  usually  markedly 
pigmented.  They  frequently  become  diseased  (particularly  in  tuberculosis),  producing  swellings, 
unusually  firm  adhesions,  and  perforation  with  the  escape  of  pus  into  the  trachea  and  the  bronchi 
(Fig.  54).  Some  of  these  same  lymphatic  glands  are  in  relation  anteriorly  with  the  posterior 
portion  of  the  pericardium  which  is  not  covered  by  the  mediastinal  pleura,  and  their  diseases 
may  consequently  extend  to  the  pericardium.  These  lymphatic  glands  are  also  of  practical 
importance  on  account  of  their  relation  to  the  esophagus  (see  below,  Plate  8,  and  Fig.  54). 

The  trachea  is  more  or  less  movable  in  the  loose  connective  tissue  of  the  mediastinum, 
although  its  walls  are  rather  rigid  from  the  presence  of  the  tracheal  rings.  It  may  be  pushed 
to  one  side  by  mediastinal  tumors,  or  even  absolutely  occluded,  particularly  when  the  tumor 
compresses  the  trachea  against  the  vertebral  column. 

The  Esophagus  [lies  partly  in  the  neck,  partly  in  the  thorax;  in  the  neck  it  begins  at  the 
level  of  the  cricoid  cartilage  in  front  of  the  sixth  cervical  vertebra. — Ed.]. — Upon  entering  the 
thorax  the  esophagus  is  behind  and  somewhat  to  the  left  of  the  trachea  (Plates  10  and  11,  and 
Fig.  54)  and  is  attached  to  the  vertebral  column  by  loose  connective  tissue.  The  esophagus 
crosses  the  tracheal  bifurcation  behind  the  origin  of  the  left  bronchus,  in  which  position  it  is 
situated  to  the  right  side  of  the  aorta  where  the  aortic  arch  ends  and  the  thoracic  aorta  com- 
mences. It  descends  along  the  right  side  of  the  aorta,  covered  by  the  right  mediastinal  pleura, 
passes  in  front  of  the  aorta,  and,  after  going  through  the  esophageal  opening  (in  front  and  some- 
what to  the  left  of  the  aortic  opening),  ends  in  the  cardiac  extremity  of  the  stomach  three  centi- 
meters below  the  diaphragm  (see  Fig.  54).  The  esophagus  may  consequently  be  exposed 
within  the  mediastinum  from  the  right  pleural  cavity  above  and  from  the  left  pleural  cavity  below; 
in  the  latter  situation  it  is  in  front  of  the  aorta.  This  is  also  the  portion  of  the  esophagus  which 
is  covered  anteriorly  by  the  pericardium  (Fig.  51). 

The  esophagus  possesses  three  narrow  portions:  (1)  At  the  cricoid  cartilage,  in  the  neck, 
where  the  contraction  of  the  inferior  constrictor  of  the  pharynx  may  offer  a  definite  resistance 
to  the  passage  of  a  sound;  (2)  at  the  level  of  the  tracheal  bifurcation;  (3)  at  the  esophageal  open- 
ing in  the  diaphragm.  The  first  narrowing  is  about  15  centimeters  from  the  incisor  teeth;  at 
the  second  narrow  portion,  which  is  about  25  centimeters  from  the  incisor  teeth,  the  esophagus 
is  in  relation  anteriorly  with  numerous  lymphatic  glands  (bronchial  glands,  see  Fig.  54).  The 
distance  between  the  third  narrowing  and  the  incisor  teeth  is  about  40  centimeters,  and  it  is 
most  frequently  the  seat  of  stricture  (in  carcinoma  of  the  cardia).  In  addition  to  these  con- 
strictions, there  are  others  which  have  recently  claimed  the  attention  of  anatomists,  but  it  remains 
to  be  seen  whether  they  are  of  any  practical  importance.  [The  average  length  of  the  esophagus 
in  the  adult  is  10  inches  (25  centimeters);  the  distance  from  the  incisor  teeth  to  its  commence- 
ment is  6  inches;  to  the  point  or  level  where  it  is  crossed  by  the  left  bronchus,  9  inches;  to  the 
esophageal  opening  of  the  diaphragm,  14  to  15  inches;  to  the  cardiac  orifice  of  the  stomach,  16 
inches. — Stiles,  in  Cunningham's  "Anatomy."] 

Foreign  bodies  which  have  entered  the  esophagus  or  pharyngeal  ulcerations  (carcinoma) 


Il6  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

may  perforate :  into  the  trachea  or  into  the  left  bronchus,  into  the  aortic  arch  or  into  the  descend- 
ing aorta,  into  either  of  the  pleural  cavities,  or  into  the  pericardium.  In  this  manner  air  may 
enter  the  pleural  cavity  from  the  mouth  (pneumothorax)  and  also  the  pericardium  (pneumo- 
pericardium) as  a  result  of  the  perforation  of  a  cancer  of  the  esophagus.  Stenosis  of  the  esoph- 
agus may  be  produced  by  the  pressure  of  an  aortic  aneurysm,  by  enlargements  of  the  bronchial 
lymphatic  glands  at  the  tracheal  bifurcation,  by  carcinoma  of  the  lung  or  of  the  pleura,  and  by 
tumors  in  the  posterior  portion  of  the  mediastinum.  Cicatricial  contraction  of  the  bronchial 
lymphatic  glands  may  lead  to  the  formation  of  the  so-called  traction  diverticula,  which  are  most 
commonly  found  in  the  anterior  wall  of  the  esophagus.  The  mucous  and  muscular  coats  of  the 
esophagus  are  united  by  a  very  loose  submucous  connective  tissue;  suppuration  may  extend 
widely  between  these  layers,  and  foreign  bodies  or  sounds  may  perforate  the  mucosa  and  make 
false  passages. 

[The  veins,  especially  at  the  lower  end,  may  be  enormously  dilated  and  varicose  in  case  of 
obstruction  to  the  portal  circulation,  owing  to  nature's  attempt  to  create  a  collateral  circulation 
between  the  veins  of  the  stomach  and  those  of  the  esophagus  (emptying  into  azygos  and  peri- 
cardiac veins),  giving  rise,  if  a  rupture  occurs,  to  severe  hemorrhage  (hematemesis). — Eisen- 
drath.] 

In  the  lower  portion  of  the  mediastinal  space  the  esophagus  is  accompanied  by  the  two 
pneumogastric  nerves,  which  pursue  a  different  course  upon  the  right  and  the  left  sides  (Plate 
10).  The  right  pneumogastric  nerve  enters  the  mediastinum  in  front  of  the  right  subclavian 
artery.  After  giving  off  the  right  inferior  or  recurrent  laryngeal  nerve,  it  passes  to  the  right 
side  of  the  innominate  artery ;  it  then  runs  alongside  of  the  trachea  and  behind  the  right  bronchus 
to  the  esophagus,  which  it  accompanies  through  the  esophageal  opening.  The  left  pneumogastric 
nerve  reaches  the  left  side  of  the  aortic  arch  between  the  left  common  carotid  and  the  left  sub- 
clavian arteries,  gives  off  the  left  inferior  laryngeal  nerve  (passing  backward  and  upward  around 
the  aortic  arch),  and  runs  behind  the  left  pulmonary  artery  and  left  bronchus  to  the  esophagus. 
(The  visceral  branches  of  the  pneumogastric  and  its  communications  with  the  sympathetic 
plexuses  should  be  reviewed  in  a  systematic  anatomy.) 

The  pneumogastric  nerves  descend  behind  the  roots  of  the  lungs,  and  when  the  pleura  is 
intact  they  may  both  be  seen  above  these  structures.  The  phrenic  nerves  run  downward  to  the 
diaphragm  beneath  the  mediastinal  pleura  and  between  it  and  the  pericardium;  they  are  accom- 
panied by  the  comes  nervi  phrenici  (branches  of  the  internal  mammary  artery).  The  phrenic 
nerves  arise  from  the  cervical  plexus  and  pass  through  the  superior  aperture  of  the  thorax  between 
the  subclavian  artery  and  vein  (see  page  71). 

The  remaining  contents  of  the  mediastinum  are  the  paired  vessels  in  front  of  the  vertebral 
column,  the  vena  azygos  major  and  vena  azygos  minor  (hemiazygos),  and  the  thoracic  duct. 

The  Vena  Azygos  Major. — In  the  abdominal  cavity  beside  the  lumbar  vertebra,  the  vena 
azygos  major  is  connected  with  the  lumbar  veins,  and  through  these  with  the  inferior  vena  cava, 
(see  page  122).  The  vessel  enters  the  thorax  through  the  right  crus  of  the  diaphragm,  ascends 
along  the  right  side  of  the  vertebral  column  (Plates  8  b  and  14),  receives  the  intercostal  veins, 
passes  over  the  right  bronchus  at  the  third  dorsal  vertebra,  and  empties  into  the  posterior  portion 
of  the  superior  vena  cava  (Fig.  51).     By  its  communication  with  the  inferior  vena  cava  it  renders 


THE   MEDIASTINUM. 


II7 


possible  a  collateral  circulation  in  the  posterior  thoracic  wall  when  this  vessel  is  occluded,  so  that 
the  blood  from  the  lower  half  of  the  body  may  reach  the  heart  through  the  superior  vena  cava. 

The  Vena  Azygos  Minor  (Hemiazygos).— This  vein  is  subject  to  considerable  variation 
(Plates  8,  a,  and  14).  Situated  at  the  left  side  of  the  vertebral  column,  it  receives  blood  from 
the  left  intercostal  veins  and  runs  across  the  ninth  dorsal  vertebra  to  empty  into  the  right  azygos 
vein.  When  there  is  a  second  communication  with  the  right  azygos  vein,  at  a  higher  level,  we 
speak  of  a  vena  hemiazygos  superior  and  of  a  vena  hemiazygos  inferior.  This  vein  is  frequently 
connected  with  the  superior  vena  cava  by  a  vessel  which  passes  transversely  across  the  aortic 
arch  and  is  known  as  the  superior  intercostal  vein  (Plate  8,  a,  where  this  vein  is  very  large,  and 
Plate  10). 

The  Tlwracic  Duct. — The  thoracic  duct  arises  from  the  receptaculum  chyli  at  the  first  or 
second  lumbar  vertebra  and  is  subject  to  many  variations,  in  its  method  of  division  and  plexus 
formation  (Plate  14).  It  is  the  main  trunk  of  the  lymphatic  system  and  accompanies  the  aorta 
through  the  aortic  opening  in  the  diaphragm.  The  duct  runs  in  the  areolar  tissue  between  the 
aorta  and  vena  azygos  major  and  then  ascends  behind  the  esophagus.  Above  the  third  dorsal 
vertebra  it  gradually  approaches  the  left  side,  is  covered  by  the  aortic  arch,  and  at  the  level  of  the 
seventh  cervical  vertebra  passes  anteriorly  between  the  left  common  carotid  and  subclavian 
arteries  to  empty  into  the  left  innominate  vein.  [According  to  some  authors,  the  highest  part 
of  the  duct  reaches  to  the  level  of  the  transverse  process  of  the  extra-cervical  vertebra.  According 
tc  Stiles,  this  is  one  inch  vertically  above  the  inner  end  of  the  clavicle.  Its  relation  to  the  inner 
border  of  the  scalenus  anticus  should  be  kept  in  mind  in  all  operations  in  this  vicinity. — Ed.] 

The  thoracic  portion  of  the  sympathetic  nerve  may  be  seen  through  the  costal  pleura  to  the 
outer  side  of  the  corresponding  azygos  vein  (Plate  8).  It  passes  into  the  thorax,  forming  the 
inferior  cervical  ganglion  in  front  of  the  head  of  the  first  rib;  the  first  thoracic  ganglion  is  situated 
anteriorly  to  the  head  of  the  second  rib,  and  the  remaining  ten  ganglia  are  in  front  of  the  heads 
of  the  lower  ribs.  It  runs  in  front  of  the  intercostal  nerves,  with  which  it  is  connected  by  visceral 
and  communicating  branches,  and  also  in  front  of  the  intercostal  arteries.  The  sympathetic 
nerve,  in  addition  to  the  branches  to  the  cardiac  plexus  and  to  the  lung,  gives  off  the  greater 
and  lesser  splanchnic  nerves,  which  run  inward  and  downward,  pass  through  the  diaphragm, 
and  end  in  the  celiac  plexus.  These  nerves  arise  by  roots  from  the  sixth  or  seventh  to  the  eleventh 
thoracic  ganglia  and,  in  consequence  of  their  white  medullated  fibers,  may  usually  be  seen  through 
the  pleura  as  they  lie  in  front  of  the  vertebral  column. 

REVIEW"  QUESTIONS. 

Why  are  penetrating  wounds  entering  the  intercostal  spaces  from  behind  more  commonly  associated 
with  injuries  to  the  ribs  than  corresponding  wounds  through  the  anterior  thoracic  wall  ? 

What  large  artery  may  be  influenced  in  its  course  by  the  presence  of  a  cervical  rib ?  What  may 
result  from  this  anomalous  relation? 

What  is  the  practical  result  of  the  preponderance  of  spongy  tissue  in  the  sternum  ? 

Into  which  three  large  cavities  (and  in  which  situations)  may  a  hemorrhage  take  place  after  an 
injury  of  the  internal  mammary  artery  ? 

What  compression  symptoms  may  follow  a  posterior  dislocation  of  the  sternal  end  of  the  clavicle  ? 


Il8  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

In  carcinoma  of  the  mammary  gland,  how  would  you  explain  the  involvement  of  the  lymphatic 
glands,  not  only  of  the  same  but  also  of  the  opposite  side  ? 

How  would  you  explain  pain  in  the  upper  arm  in  a  case  of  mammary  carcinoma  ? 

What  practical  results  may  be  deduced  from  the  position  of  the  intercostal  arteries? 

Why  are  diaphragmatic  hernias  more  common  upon  the  left  side?  Where  is  the  seat  of  predilec- 
tion for  such  a  hernia  ? 

Which  large  vessel  may  be  injuriously  affected,  at  its  passage  through  the  diaphragm,  by  a  large 
pleuritic  exudate  ? 

How  do  you  explain  the  rarity  of  injuries  of  the  pleura  without  concomitant  injuries  of  the  lung? 

Along  what  path  may  inflammations  in  the  neighborhood  of  the  cervical  viscera  easily  extend 
into  the  mediastinum? 

Why  are  injuries  of  the  ventricles  of  the  heart  more  common  than  injuries  of  the  auricles  ? 

What  are  the  practical  results  of  the  relation  of  the  esophagus  to  the  pericardium? 

Where  is  the  most  favorable  location  for  tapping  the  pericardial  sac? 

What  is  the  anatomic  explanation  of  the  influence  of  disease  of  the  lungs  and  of  the  pleural  cav- 
ities upon  the  extent  of  the  cardiac  dulness  and  upon  the  position  of  the  heart? 

Into  which  cavity  will  a  ruptured  aneurysm  of  the  ascending  aorta  usually  empty? 

What  vessel  to  the  right  and  what  one  to  the  left  will  be  compressed  by  such  an  aneurysm? 

What  structures  may  be  affected  by  aneurysms  of  the  aortic  arch? 

What  is  the  explanation  of  the  occurrence  of  a  paralysis  of  the  left  vocal  cord  in  aneurysm  of  the 
aortic  arch  ? 

Why  do  foreign  bodies,  which  have  gained  access  to  the  larynx,  pass  more  readily  into  the  right 
than  into  the  left  bronchus? 

Where  are  the  three  narrow  portions  of  the  esophagus  and  how  far  are  they  from  the  incisor  teeth  ? 

What  is  the  most  probable  cause  of  a  fatal  hemorrhage  after  swallowing  a  pointed  instrument  or 
in  a  case  of  esophageal  carcinoma  ? 

In  what  manner  may  an  affection  of  the  esophagus  lead  to  pneumothorax  or  pneumopericardium? 

What  practical  facts  must  be  remembered  in  reference  to  the  very  loose  character  of  the  submucous 
tissue  of  the  esophagus  ? 

What  vein  may,  under  certain  circumstances,  transmit  the  blood  from  the  lower  half  of  the  body 
to  the  heart  when  the  circulation  is  disturbed  in  the  trunk  of  the  inferior  vena  cava  ?  What  path  does 
the  blood  take  in  such  a  case  ? 


THE   ABDOMEN. 

THE  ABDOMINAL  WALL. 

The  superior  external  boundary  of  the  abdomen,  the  dividing-line  between  the  abdomen 
and  the  thorax,  is  formed  by  the  inferior  aperture  of  the  thorax  (see  page  92),  which  may  be  both 
seen  and  palpated.  The  inferior  external  boundary,  the  dividing-line  between  the  abdomen 
and  the  pelvic  and  femoral  regions,  is  furnished  by  the  iliac  crests,  the  groins  (corresponding 
with  Poupart's  ligament),  and  the  symphysis  pubis.  The  internal  boundaries,  or  the  lines  of 
separation  between  the  abdominal  cavity  and  the  thoracic  and  pelvic  cavities,  do  not  correspond 
with  the  external  ones.     The  dome  of  the  diaphragm  extends  far  above  the  inferior  aperture  of 


THE  ABDOMINAL  WALL.  ng 

the  thorax  and  the  upper  limit  of  the  abdominal  cavity;  the  diaphragm  consequently  corre- 
sponds with  the  lower  limit  of  the  thoracic  cavity.  The  abdominal  cavity  also  extends  down- 
ward below  the  external  boundary,  formed  by  the  iliac  crests,  and,  although  there  is  really  no 
sharp  demarcation  between  the  abdomen  and  pelvis,  we  designate  the  linea  terminalis  (pelvic 
brim),  the  dividing-line  between  the  true  and  false  pelvis,  as  the  inferior  boundary  of  the  abdom- 
inal cavity. 

Inspection  and  Palpation.— Inspection  and  palpation  reveal  a  number  of  superficial 
landmarks.  The  anterior  median  furrow  of  the  thorax,  passing  into  the  scrobiculus  cordis 
(see  page  91),  is  continued  downward  in  the  direction  of  the  linea  alba,  and  in  spare  muscular 
individuals  may  be  traced  to  the  navel  or  even  to  the  mons  Veneris  over  the  symphysis.  To  either 
side  of  this  median  furrow  may  be  observed  the  prominences  caused  by  the  recti  muscles,  the 
external  margins  of  which  may  be  located  by  the  presence  of  more  or  less  distinct  shallow  grooves. 
[The  linea  semilunares  are  represented  by  slightly  curved  lines  from  the  tip  of  the  ninth  costal  carti- 
lages to  the  pubic  spines. — Ed.]  The  furrows  running  transversely  across  the  prominences  of 
the  recti  muscles  correspond  to  their  tendinous  intersections ;  the  portions  of  muscle  situated  be- 
tween these  tendinous  intersections  are  occasionally  so  prominent  that  they  may  simulate  tumors 
(lipomata).  [Occasionally,  particularly  when  there  is  tenderness  beneath,  they  simulate  intra- 
abdominal tumors. — Ed.]  None  of  these  landmarks  are  visible  in  the  female,  on  account  of  the 
abundance  of  subcutaneous  fat ;  during  pregnancy  the  anterior  median  line  of  the  abdomen  is  ren- 
dered visible  by  the  formation  of  pigment  in  the  skin  over  the  linea  alba.  With  the  subject  in 
the  dorsal  position,  the  vertebral  column  and  the  pulsations  of  the  abdominal  aorta  may  be  pal- 
pated if  the  abdominal  walls  are  relaxed  and  not  too  thick. 

Upon  the  dorsal  surface  the  posterior  median  furrow  is  continued  downward  over  the  spin- 
ous processes  to  the  sacrum  and  terminates  in  the  shallow  fossa  which  is  designated  as  the  sacral 
triangle.  The  posterior  surface  of  the  sacrum  may  be  felt  in  this  region  and,  lower  down,  the 
slightly  movable  coccyx.  The  palpating  finger  may  be  passed  along  the  iliac  crest  to  the  anterior 
superior  spine  of  the  ilium,  and  from  here  along  the  groin,  upon  Poupart's  ligament,  to  the  hori- 
zontal ramus  of  the  pubis  and  the  pubic  symphysis.  [The  posterior  superior  spinous  processes 
of  the  ilium  are  palpable,  usually  indicated  by  a  depression,  and  are  on  the  level  of  the  spinous 
process  of  the  second  sacral  vertebra. — Ed.] 

The  following  lines  are  employed  to  divide  the  external  surface  of  the  abdomen  into  regions: 
A  horizontal  line  is  drawn  about  the  chest  at  the  level  of  the  root  of  the  xiphoid  process  and  serves 
as  a  dividing-line  between  the  chest  and  abdomen.  A  second  line  is  drawn  anteriorly  connecting 
the  two  lowest  points  of  the  costal  margin  and  running  posteriorly  along  the  lower  border  of  the 
ribs  to  the  twelfth  dorsal  vertebra.  The  epigastric  region  is  situated  between  these  two  lines. 
The  central  portion  of  the  epigastric  region,  bounded  laterally  by  the  costal  margins,  is  known 
as  the  epigastrium;  the  remainder  of  this  region  forms  the  two  hypochondriac  regions,  which 
contain  those  abdominal  organs  which  are  situated  beneath  the  costal  margins.  Below  the  epi- 
gastric region  is  the  mesogastric  region,  which  extends  downward,  anteriorly  to  a  line  connecting 
the  two  anterior  superior  spines,  laterally  and  posteriorly  to  the  iliac  crests.  The  space 
bounded  by  the  line  connecting  the  anterior  superior  spines  of  the  ilium,  by  the  groins,  and  by 
the  symphysis  is  known  as  the  hypogastric  region.     Lines  drawn  downward  from  the  lowest 


120  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE  11. 
The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy.     Anterior  view.     From  an  accurate  Leipzig  model 
made  from  an  original  dissection. 

PLATE  12. 
The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy.     Posterior  view.     From  the  model  of  Plate  n. 

points  of  the  costal  margins  to  the  pubic  spines  subdivide  the  mesogastric  region  into  a  central 
umbilical  region  and  two  lateral  abdominal  regions;  they  also  subdivide  the  hypogastric  region 
into  a  central  pubic  region  and  two  lateral  or  inguinal  regions.  The  lumbar  regions  are  in  the 
posterior  portion  of  the  mesogastric  region  and  extend  from  the  spinal  column  to  a  line  which 
represents  the  shortest  distance  between  the  costal  margin  and  the  crest  of  the  ilium.  [This 
manner  of  delimiting  the  abdominal  regions  differs  from  that  adopetd  by  English  writers  and 
even  from  other  German  authors. — Ed.] 

The  skin  0}  the  abdomen  is  comparatively  thin  and  movable,  except  at  the  navel;  it  is  also 
very  elastic,  as  is  shown  by  the  distention  produced  by  tumors,  ascites,  or  pregnancy.  The  so- 
called  stria  gravidarum  are  not  an  absolute  indication  of  a  preceding  pregnancy,  since  they  may 
be  produced  by  any  distention  of  the  abdominal  integument.  The  fat  in  the  subcutaneous  con- 
nective tissue  is  often  so  pronounced  that  it  interferes  with  the  palpation  of  the  internal  organs 
and  is  a  disturbing  factor  in  the  performance  of  laparotomy. 

Muscles.— In  contrast  to  the  thoracic  wall,  the  greater  portion  of  the  abdominal  wall  is 
composed  of  muscular  tissue ;  the  palpation  of  the  abdomen  is  consequently  of  more  importance 
than  the  palpation  of  the  thorax.  The  abdominal  muscles  extend  between  the  inferior  aperture 
of  the  thorax,  the  transverse  processes  of  the  lumbar  vertebras,  the  iliac  crest,  the  symphysis, 
and  Poupart's  ligament.  The  rectus  abdominis  muscle  arises  from  the  outer  surfaces  of  the  fifth 
to  the  seventh  costal  cartilages  and  from  the  xiphoid  process,  and  is  inserted  into  and  alongside 
of  the  anterior  surface  of  the  symphysis.  It  is  surrounded  by  a  fibrous  sheath  which  is  complete 
anteriorly,  but  on  the  posterior  surface  of  the  muscle  it  extends  only  two  fingerbreadths  below 
the  navel  (linea  semicircularis  Douglasi),  so  that  the  only  structures  beneath  the  muscle  in  this 
situation  are  the  thin  transversalis  fascia  and  the  peritoneum.  The  aponeuroses  of  the  three 
flat  abdominal  muscles  are  united  in  the  median  line  to  form  the  linea  alba,  which  contains  few 
blood-vessels  and  is  consequently  frequently  chosen  as  the  site  of  the  incision  for  operative  pro- 
cedures upon  the  abdomen.  Above  the  umbilicus,  it  is  broader  and  thinner;  while  below,  it 
is  narrower  and  thicker.  [Below  the  navel,  owing  to  the  fact  that  the  recti  are  more  closely 
approximated, — in  the  lower  fourth  the  aponeuroses  all  pass  in  front  of  the  recti, — the  linea 
alba  is  often  scarcely  apparent. — Ed.]  The  greater  breadth  above  the  navel  is  responsible  for  the 
fact  that  hernias  of  the  linea  alba  are  more  frequent  above  than  below  this  location.  These 
hernias  pass  through  the  slit-like  orifices  which  transmit  the  vessels  from  the  underlying  struc- 
tures to  the  skin.  The  external  oblique  muscle  of  the  abdomen  is  situated  beneath  the  super- 
ficial fascia;  it  arises  from  the  outer  surfaces  of  the  seven  or  eight  lower  ribs  and  is  inserted  into 
the  linea  alba,  the  outer  lip  of  the  iliac  crest, — anterior  one-half, — and  Poupart's  ligament.  Under- 
lying this  muscle  is  the  internal  oblique,  which  arises  from  the  lumbar  fascia,  from  the  middle 
lip  of  the  iliac  crest  [anterior  two-thirds. — Ed.],  and  from  Poupart's  ligament,  and  is  inserted  into 
the  ends  of  the  tenth  to  the  twelfth  ribs  and  into  the  linea  alba.     [By  means  of  its  aponeurosis 


11 


Trachea 


Vertebra  cervicalie  VII 
Seventh  cervical  vertebra 


V.  thyreoidea  ima 
Middle  thyroid  v. 

Innominate  a. 


V.  a 


Falciform  ligament 


Gallbladder 


Poupart's  ligament 


Iliopsoas  m 
A.  Fe5"0"1*- 


Obturator  foramen 


linistra 

Left  subclavian  a. 


Incisure  cardiaca  of  left  lung 
Incisura  interlobaris 


Diaphragm 


Round  ligament 


Eleventh  rib 


Iliac  crest 


Spermatic  cord 


Tuberosity  of  ischium 


Bladder 


fentoneum 


120 


M 


fiidstia/  UDrvm 


i.-irf  Ml  I 


eugfirfqosH „ 


I   UKnirnonai  JfaJ. 
.*  mi   nl    flihlfcfl 

gaul  to  xsqA- 

■ 

-limiting 

/ 
skin  of  the  ab<tt 


■  i  fii.nyrll  -,fbbil/ 

..>.   )!i;nirnoaaI 


-.  /  3U.nimonfli  iri&iM 


inal  r< 

tend  from  the^j 

I  margin  and  thY 

-  from  that  adop^td  b 

cnparatively  thin  and  movable,  except  at  the  na\< 


snoiiW.to^iUsB^fiiiKimi-/ uiion  produced  by  tumors,  as<       ]       ;>regi 

A  an  absolute  indication  of  a  preceding  pregr 
"     iUon  of  the  abdominal  integument.     The  fat  In 


T  by  am 


issue  is  oftin  s  ^pronounced  that  it  interferes  with  the  palpation  of  the  in 
.  distui  or  in  the  performance  of  laparotomy. 

Mtiscles.-^i;.  (urtr:  he  thoracic  wall,  the  greater  portion  cjf  the  abdominal 

ular   issue;  the  palpation. of  the  libUuini'ii  is  luiisi'ijufi/fr?"^  Wftfe'    iportance 
palpation  of  trip  thorax.     The  abdominal  muscles  extend  between  the  inferior  aperture 
frrftti*1, ftftof1  transWrsc.  professes  of  the  lwmbar  vertebras,  the  mac  crest,  the  symph 

irt's  ligament. \  The  rectus  abdominis  muscle '2lt\ *Sh«nwiaces  of  the  fifth 

md  from  the  xiphoid  process,  and  if  inserted  into  and  a 

is  surrounded  by  a  fibrous  sheath  which  is  com} 
[         -  fingerbreadths  I 
ith  the  n 


-tal  ca 

the  abd 
i*  narrower  and  thick 
approxii.  in  the 

alba 

\nar>  iilfinr«q8  _ 


ind  thinner;  wl 
t  that  tl/ 


•In-jrai;8il  s'Jiequol 


muirf^i  lo  ni'wnduT 


><qoiII 


I 


l*x.rrm 


I9bb«ia 
imwnotrnfl  nam 

-  !fth  ribs  and  a  alV 


# 


Tab.  II. 


Trachea 


V.  thyreoidea  ima 
A.  anonyma. 

V.  anonyma  dextra 


Vertebra  cervicalis  VII 

Oesophagus 

A.  carotis 
..-''  sin 


Lig.  falciforme  hepatis 


Vesica  fellea- 


Lig.  inguinale 
(Pouparti) 


M.  iliopsoas 

A.  femoralis 


V.  anonyma  sinistra 

A.  suJclavia  sin. 

Apex  pulmonis 


Incisura  cardiaca  pulmonis  sin. 
--Incisura  interlobaris 


Diaphragma 


Lig.  teres 


Costa  XI 


Crista  iliaca 


Funiculus  spermaticus 


Tuber  ischiadicum 


V.  femoralis 

Vesica  urinaria 
Foramen  obturatum  Peritonaeum 


12 


First  rib 


Left  hing 


Great  sacrosciatic  lig 


Rectum 
Tuberosity  of  ischium 


Right  lung 


Lower  border  of  lung 
Diaphragm 

liver 
—Right  kidney 

-  Psoas  m. 
Ascending  colon 


Small  intestine 

Lesser  sacrosciatic  lig. 

Bladder  ^    urinftfi* 
Obturator  foramen 


LL 


dn  iaii'4 


Soul  JrisiM 


jjnul  io  tabled  tswoJ 


saitestai  llemi: 

•ail  iu.Mv.au.-  mm  i 

lobbaW 


anul  JlsJ 


gil  jiiKi  miiih  >j»n.) 


mu)39>! 
rnuiriwi  lo  < ligoisduT 


Tab.  12. 


Costa  I 


Pulmo  sinister:. 


Costa  XII 
Lien 

Ren  sinister 
Colon  descendens 

Intestinum  tenue 


Lig.  sacro-tuberosum 


Rectum 


Tuber  ischiadicum 


Pulmo  dexter 


-Margo  inferior  pulmonis 
Diaphragma 

-Hepar 

I R.en  dexter 

M.  psoas 

Colon  ascendens 


. Jf     Intestinum  tenue 

Wf. Lig.  sacro8pinosum 

f_ Vesica  urinaria 

Foramen  obturatum 


THE   ABDOMINAL   WALL.  12i 

it  is  also  inserted  into  the  cartilages  of  the  eighth,  ninth,  and  tenth  ribs.— Ed.].  The  most  internal 
muscle  is  the  transversalis,  which  takes  origin  from  the  inner  surfaces  of  the  six  lower  costal 
cartilages,  from  the  deep  layer  of  the  lumbar  fascia,  from  the  inner  lip  of  the  iliac  crest,  and  from 
Poupart's  ligament,  and  inserts  into  the  linea  alba.  The  aponeurosis  of  the  external  oblique 
passes  only  into  the  anterior  layer  of  the  sheath  of  the  rectus;  that  of  the  internal  oblique  runs 
in  both  layers  of  the  sheath,  and  the  aponeurosis  of  the  transversalis  muscle  is  found  in  the  pos- 
terior portion  of  the  sheath  above  the  semilunar  line  of  Douglas  and  in  the  anterior  portion  below 
it.  Posteriorly  alongside  of  the  vertebral  column  in  the  lumbar  region  is  the  quadratus  lumborum 
muscle,  which  extends  between  the  transverse  processes  of  the  lumbar  vertebras,  the  last  rib,  and 
the  posterior  portion  of  the  iliac  crest.  This  muscle  holds  a  most  important  relation  to  the  kidney 
(see  page  139).  The  fascia  0)  Retzius  varies  considerably  in  different  individuals;  it  seems  to 
form  a  feeble  continuation  of  the  posterior  layer  of  the  sheath  of  the  rectus.  Behind  this  fascia, 
between  the  transversalis  muscle  and  the  peritoneum,  is  the  transversalis  fascia,  which  passes 
upward  to  the  inferior  surface  of  the  diaphragm.  It  is  thin  above  the  umbilicus  and  in  the  umbil- 
ical region,  but  becomes  thicker  in  the  inguinal  region  and  is  attached  to  the  internal  Up  of  the 
iliac  crest  and  to  Poupart's  ligament.  Just  above  the  umbilicus,  the  transversalis  fascia  is  known 
as  the  umbilical  fascia  but  this  latter  structure  is  subject  to  great  variation  and  has  received 
more  attention  than  it  deserves  from  a  practical  standpoint. 

The  arteries  of  the  abdominal  wall  are  to  be  differentiated  as  the  superficial  and  the  deep. 

The  superficial  vessels  arise  from  the  femoral  artery.  They  are  the  superficial  epigastric 
and  the  superficial  circumflex  iliac  (Fig.  77).  The  superficial  epigastric  artery  is  not  a  partic- 
ularly large  vessel;  it  perforates  the  fascia  lata  below  Poupart's  ligament  and  passes  upward 
over  this  ligament  toward  the  navel,  although  it  does  not  run  as  far  as  the  latter  structure.  The 
superficial  circumflex  iliac  also  perforates  the  fascia  lata  and  runs  parallel  to  Poupart's  ligament 
to  the  skin  in  the  region  of  the  anterior  superior  spine  of  the  ilium.  Both  arteries  are  of  practical 
importance,  since  they  supply  the  so-called  inguinal  glands. 

The  deep  arteries  are  much  larger.     They  are: 

1.  The  seven  lowermost  intercostal  arteries  which  run  beyond  the  costal  margin  and  end  in 
the  abdominal  muscles. 

2.  The  inferior  or  deep  epigastric  artery  (Figs.  56  and  71),  practically  the  most  important 
vessel  in  the  anterior  abdominal  wall,  arises  from  the  external  iliac  just  before  it  passes  beneath 
Poupart's  ligament.  It  runs  upward  in  a  curved  direction,  the  concavity  being  directed  outward, 
passing  to  the  inner  side  of  the  internal  abdominal  ring;  the  vessel  is  situated  just  beneath  the 
peritoneum  forming  the  plica  epigastrica  (see  page  123  and  Figs.  56  and  58).  At  the  fold  of 
Douglas  it  enters  the  sheath  of  the  rectus  and  anastomoses  freely  above  the  umbilicus  with  the 
superior  epigastric  artery  (see  page  94).  If  the  circulation  in  the  descending  aorta  is  obstructed, 
these  anastomoses  may  become  dilated  and  form  a  collateral  path,  through  which  the  blood  from 
the  subclavian  artery  may  pass  along  the  inner  surface  of  the  thoracic  and  abdominal  walls  to 
reach  the  lower  extremity.  The  course  of  the  inferior  epigastric  artery  corresponds  to  a  line 
drawn  from  the  junction  of  the  inner  and  middle  thirds  of  Poupart's  ligament  to  a  point  one  inch 
to  the  outer  side  of  the  navel.  To  avoid  the  artery  in  tapping  for  ascites  or  in  other  operative 
procedures  the  puncture  should  be  made  either  to  the  outer  side  of  the  vessel  at  Monro's  point 


122  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE  13. 
The  position  of  the  thoracic  and  abdominal  viscera  of  a  boy,  seen  from  the  left  and  from  the  right.     From  the  mode, 
of  Plate  ii. 

Fig.  55. — A  diagrammatic  representation  of  the  communications  between  the  superior  and  inferior  venae  cavse  and 
the  portal  vein. 

in  the  middle  of  the  so-called  Richter-Monro  line,  drawn  from  the  anterior  superior  spine  of  the 
ilium  to  the  navel,  or  to  the  inner  side  of  the  vessel  (Naunyn)  through  the  rectus  abdominis  muscle, 
three  centimeters  from  the  linea  alba  midway  between  the  navel  and  the  symphysis. 

3.  The  deep  circumflex  iliac  artery,  the  remaining  branch  of  the  external  iliac,  passes  outward 
along  the  iliac  crest  and  then  upward  to  supply  the  abdominal  muscles;  upon  the  iliacus  muscle 
it  anastomoses  with  the  iliac  branch  of  the  iliolumbar  artery  (from  the  internal  iliac). 

4.  The  four  pairs  of  lumbar  arteries  which  arise  from  the  abdominal  aorta  pass  in  front  oi 
the  bodies  of  the  first  to  the  fourth  lumbar  vertebras  beneath  the  tendinous  arch  of  origin  of  the 
psoas  muscle,  and  run  partly  in  front  of  and  partly  behind  the  quadratus  lumborum  to  the  mus- 
culature of  the  lateral  abdominal  wall. 

The  veins  of  the  abdominal  wall  may  also  be  divided  into  a  superficial  and  a  deep  set 

(Fig-  55)- 

The  superficial  or  subcutaneous  veins  are  the  superficial  epigastric  and  the  superficial  cir- 
cumflex iliac;  they  are  considerably  larger  than  the  arteries  of  the  same  name  which  they  accom- 
pany, and  empty  into  the  femoral  vein  below  Poupart's  ligament.  The  superficial  epigastric 
vein  anastomoses  above  with  the  long  thoracic  through  the  thoracico-epigastric  vein,  and  thus 
aids  in  the  formation  of  a  subcutaneous  venous  connection  in  the  thoracic  and  abdominal  walls 
between  the  axillary  and  the  femoral  veins. 

The  deep  veins  are  the  vena  comites  of  the  inferior  epigastric  artery  (which  anastomose 
above  with  the  superior  epigastric  branch  of  the  internal  mammary  vein),  the  venae  comites  of 
the  superficial  circumflex  iliac  artery,  and  the  single  lumbar  veins  (which  run  above  their  accom- 
panying lumbar  artery).  The  vertical  anastomoses  of  the  lumbar  veins  behind  the  psoas  muscle 
form  the  ascending  lumbar  veins  upon  each  side  which  give  origin  to  the  vena  azygos  major  and 
minor.  In  this  manner  a  venous  communication  is  formed  between  the  superior  and  inferior 
vena  cava  in  the  posterior  portion  of  the  body;  the  importance  of  this  venous  connection  has 
been  previously  emphasized  (see  page  116).  A  stasis  in  the  inferior  vena  cava  may  ilso  make 
itself  visible  through  the  anterior  abdominal  wall,  since  the  blood  from  the  inferior  vena  cava 
tries  to  reach  the  superior  vena  cava  through  the  dilated  superficial  epigastric  veins. 

The  superficial  veins  of  the  abdominal  wall  form  a  subcutaneous  venous  plexus  which  com- 
municates with  the  area  drained  by  the  deep  epigastric  veins  by  means  of  numerous  anastomoses 
passing  through  the  abdominal  wall  (Fig.  55).  These  anastomoses  are  also  directly  con- 
nected with  the  portal  vein,  on  the  inferior  surface  of  the  liver,  by  four  or  five  small 
parumbilical  veins  (accessory  portal  branches)  which  pass  along  the  round  ligament  of 
the  liver.  The  portal  vein  enters  the  liver  at  the  porta  hepatis  and  arises  from  the 
veins  of  the  stomach,  of  the  intestines,  of  the  spleen,  and  of  the  pancreas.  Diseases  of 
the  liver — cirrhosis,  for  example — easily  produce  stasis  in  the  venous  radicals  of  the  portal 
vein    and  transudation  from  the  vessels  in  the    organs    which    have    just    been   mentioned; 


13 


TrEM! 


Upper  lobe  of  left  hwig 


Lower  lobe  of  left  lung 
sin. 


Poupart's  lig;ment 
Acetabulum 


A&thl  Uttfcnonis 

•Pj«bi  in*9«naatd«c. 


Upper  I"!*-  <>f  rmhi  lung 


Middle  lobe  of  right 
lung 


l.iiwei  satroscialK 
Great  sacrosci-    llora 
atfc  fig. 
tuberosum 


TOPOGRAPHIC    A 


PLATE  11 

#U»on  of  the  thoracic  and  abdominal  viscera  oi 


£1 

•Srammatic  representation 
«tfirm  IssWtoi  dmrtaZi 
gnu!  lo  x-xjA* 

^  the  n^^J^^^m 
m  to  the  navel,  or  to  tht 
three  centimeters  from  t] 

3.  The  deep  circuwq 

aktftffffehto  ilW(*>«jv  *-« f 

it  anastomose 

4.  The  four  [1 


I 

>ranch  of  th< 


i'  ilioli 


the  aidominal  mu~ 
ibar/artcrv  (from  the  interne 


-anul  liol  lo  50VI  vjcjcj'J 


lrleries  whichN 


fffu^cle,  andjrun  partly  in  front  of  and  pahly  behind  the  quadrv 


,        ^  >urth  lumbar  vertebras  >eneath  the  tendinous  arch  of 


'         abdominal  wall. 
the  abdominal  wall  may 


irtery 
from  the  abdominal  aorta 


so  beVdivided  irfT6  a  superlici.i 


.  jjnul  rtsi  lo  sdol 


culature  of  the 

The  veins 
(Fig-  55). 

Xbftd4U0LHi  Ml  or. subcutaneous  veins  arcJthe  superficial  epigastric  and  the  sujk  \ 
cumfiex  iliac  re  considerably  larger  tha/ the  arteries  of  the  same  name  which  li  ) —  Wt6** ' 

pany,  anc^pt;    into  the  femoral  vein  belo/v  Poupar A  ligament..    Tho  tAipurfu L— . 

vein  anastomoses  above  with  the  long  thoracic  fovnu&t  4jVth6Tacico-epiga*«e-» \        .  rf^oia 

aids  "AbLhjMute>r'^/t.ion  of  a  subcutaneous  veTnous  connectionj^thc  thoracic  and  abdomiirff 
betwt  c H«^e%Ttt^ry  and  the  femoral  VeWY,flbL}I       "^Stote 

above  with  the 
theuBpHMMqa 

ng  lumbar 

.  -id i? 

noku  ynihiri  <^/. \  • 

•••IPr.    Tn  this  nlann. 

in  the  posterior  1/ 

\  /\       D,""n"' 

wal,  sine 
;h  the  tlilatc 

l 


try  and  the  femoral  v< 
rrus  c 

:umh\ 

lumbo 


»k*fte  inferior  epifestfic  artery  (which  anat;:      n 
nfert"3  ifa wnj^^wt .niflrryahry  vein ) ,        j  Jnites  of 


the  anterior  abdomin; 


•'mfar.n^  *-v       ich  run  abort 
of  the  lumttar  veins  behind  th-  | 

■•  w  tow  ft  gi      /         to  the  1 

'    riiui   j 


1 
parumbii.    \ 
liver. 


i'iiii?<'>mi 

■rrrW'^1 

m  Am  hioarni?. 

)nirn«ij)il  *' Usque 


.  amlufii.fi  j  A 


l->mi;iol] 

.gil 


Tab.  13. 


Oesophagus 
Trachea 


Lobus  sup.  pulm.  sin.- 


Vertebra   cervicalis  VII 
Apex  pulmonis 
A.  anonyma 
V.  anonyma  dex. 


Lobus  sup. 
pulm.  dex. 


Lobus  med. 
pulm.  dex. 


Lobus  inf.  pulm 
sin. 


Diaphragma 

Lien- 

Ventriculus ~- 


Colon  trans- 
versum 

Intestinum      , 
tenue       ~~~  --. 


Crista  iliaca— 


Colon  sigmoi 
deum 

Lig.  inguinale 
(Pouparti) 

Acetabulum 


Lig. 
sacrospinosum 
For.  ischiad.  min. 
Lig.  sacro- 
tuberosum 


%  55- 


Right  innominate  vein 


Internal  mammary  vein 


Parumbilical  veins 


Anastomoses  between  the  superficial 
and  deep  epigastric  veins 


Deep  epigastric   veins 
Right  comon   iliac  vein 

Superficial  epigastric  vein 
External  iliac  vein 

Internal  pudic  vein 


Left  innominate  vein 

Superior  vena  cava 
Vena  azygos  maior 

Esophageal  veins 

Anastomoses  at  the  cardiac    end   of 
the  stomach 


Coronary  vein  of  stomach 
Portal  vein 


Splenic  vein 

Superior  mesenteric  vein 

Inferior  mesenteric  vein 
Inferior  vena  cava 

Left  common  iliac  vein 


Superior  hemorrhoidal  vein 
Internal  iliac  vein 


Hemorrhoidal  plexus 


THE  ABDOMINAL  WALL.  I2$ 

it  is  in  this  manner  that  ascites  is  produced.  In  addition  to  ascites,  there  are  three  other  symp- 
toms or  signs  of  obstruction,  dependent  upon  three  other  sets  of  veins  aiding  in  the  formation  of 
the  portal  circulation,  which  are  readily  understood  if  we  are  acquainted  with  the  normal  anas- 
tomoses of  these  veins. 

i.  There  is  a  stasis  in  the  venous  hemorrhoidal  plexus,  in  the  neighborhood  of  the  rectum, 
from  which  the  blood  passes  through  the  superior  hemorrhoidal  vein  to  the  inferior  mesenteric 
and  thus  reaches  the  portal  vein.  In  this  manner  hemorrhoids  are  produced.  From  this  same 
plexus  the  blood  flows  through  the  middle  and  inferior  hemorrhoidal  veins  into  the  internal 
pudic  vein  and  finally  reaches  the  inferior  vena  cava. 

2.  There  is  passive  congestion  of  the  lesser  curvature  of  the  stomach  and  of  the  lower  end 
of  the  esophagus  due  to  stasis  in  the  coronary  vein  of  the  stomach.  This  may  lead  to  dilatation 
of  the  veins  (esophageal  varices)  and  even  to  rupture  of  these  vessels  with  a  consequent  hema- 
temesis;  it  is  possible,  however,  for  the  blood  in  the  esophageal  veins  to  flow  into  the  vena  azygos 
major. 

3.  As  a  result  of  passive  congestion  and  dilatation  of  the  parumbilical  veins,  the  veins  of  the 
abdominal  wall  also  become  dilated ;  these  veins  are  partly  arranged  in  a  radiating  manner  about 
the  umbilicus,  and  the  so-called  caput  Medusae  is  thus  produced.  [The  Talma-Morrison  opera- 
tion for  the  relief  of  cirrhosis,  whereby  the  great  omentum  is  caused  to  form  adhesions  and  venous 
connections  with  the  abdominal  wall,  is  based  on  this  venous  anastomosis. — Ed.] 

The  nerves  of  the  abdominal  wall  are  the  terminal  portions  of  the  six  lower  intercostal 
nerves,  which  pass  beyond  the  costal  margin  and  reach  the  rectus  abdominis  between  the  flat 
abdominal  muscles.  In  addition  to  these  there  are  the  ilio- hypo  gastric  and  the  ilio-inguinal  nerves 
from  the  lumbar  plexus.  All  these  nerves  supply  the  muscles  of  the  abdominal  wall  and  give  off 
lateral  and  anterior  cutaneous  branches.  There  are  also  a  number  of  nerves  from  the  lumbar 
plexus  which  are  situated  between  the  muscles  of  the  posterior  abdominal  wall  (iliopsoas,  quad- 
ratus  lumborum,  transversalis)  and  the  peritoneum.  They  are  the  external  cutaneous,  the  genito- 
crural,  and  the  anterior  crural  nerves.  The  external  cutaneous  nerve  runs  transversely  across  the 
iliacus  muscle  toward  the  anterior  superior  spine  of  the  ilium.  The  genitocrural  nerve  sub- 
divides into  a  crural  branch,  to  the  skin  of  the  subinguinal  region,  and  a  genital  branch,  passing 
through  the  inguinal  canal  to  the  cremaster  muscle.  The  anterior  crural  nerve  is  easily  found  in 
the  iliac  fossa  between  the  psoas  and  iliacus  muscles  and,  with  the  exception  of  the  sciatic,  is  the 
longest  nerve  of  the  lower  extremity  (see  page  161).  [Pleuritic  pain,  particularly  when  located 
low  and  near  the  diaphragm,  is  often  referred  to  the  abdominal  wall  along  the  terminations  of  the 
lower  intercostal  nerves,  and  is  sometimes  mistaken  for  abdominal  disease. — Ed.] 

The  topography  of  the  inner  surface  0}  the  anterior  abdominal  wall,  under  normal  tension, 
is  of  great  importance  for  the  proper  understanding  of  inguinal  and  femoral  hernia  (Figs.  56  to 
58).  The  peritoneum  is  reflected  over  a  number  of  underlying  cords  and  thus  forms  folds  which 
have  received  special  names.  In  the  middle  line  the  plica  umbilicalis  media  passes  upward  from 
the  bladder  to  the  navel;  it  is  produced  by  the  ligamentum  umbilicale  medium,  the  urachus  of 
fetal  life,  which  is  situated  beneath  the  peritoneum.  To  either  side  of  the  bladder,  the  obliterated 
remains  of  the  hypogastric  arteries,  the  ligamenta  umbilicalia  lateralia  of  adult  life,  form  the 
plica  umbilicales  laterales.     Still  more  externally  are  the  less  pronounced  plicce  epigastric^,  which 


124 


TOPOGRAPHIC    AND    APPLIED    ANATOMY. 


Fig.  56. — The  inferior  half  of  the  anterior  abdominal  wall  as  seen  from  within.  The  pelvis  is  shown  in  frontal 
section.  The  greater  portion  of  the  peritoneum  has  been  left  intact,  but  portions  of  it  have  been  removed  upon  the 
right  from  the  internal  abdominal  ring,  upon  the  left  from  the  epigastric  vessels,  the  lateral  umbilical  ligament  and  the 
vas  deferens,  and  in  the  middle  line  from  the  median  umbilical  ligament. 

Fig.  57. — In  the  left  iliac  fossa  the  layers  of  the  abdominal  wall  are  shown,  the  dissection  exposing  the  sigmoid  colon. 
The  recti  muscles  are  divided  and  the  urinary  bladder  has  been  made  visible  above  the  symphysis  without  injuring  the 
peritoneum.     Upon  the  right  side  there  is  an  internal  inguinal  hernia. 

contain  the  inferior  (deep)  epigastric  artery  and  veins.  The  vas  deferens  may  also  be  seen  beneath 
the  peritoneum  and  palpated  as  a  hard  cord;  it  is  situated  to  the  outer  side  of  the  epigastric  fold. 
In  this  situation  it  leaves  the  inguinal  canal  to  pass  into  the  true  pelvis  behind  the  bladder.     This 


Skin 

Peritoneum 

Rectus  abdom- 
inis m. 


Edge  of  rectus 
muscle 


Falx  inguinalis 

Middle  inguinal 

fossa 

Plica  umbili- 

calis  lateralis 

Sac  of  femoral 

hernia 

Symphysis 

Plica  umbili- 

calis  media 


Cavity  of 
bladder 
Bladder 


Plica  epigas- 
trica 


Lateral  inguinal 
fossa 


External  ob- 
lique muscle 

Internal  ob- 
lique muscle 

Transversalis 
muscle 


Vas  deferens 


FlG.  58. — The  inferior  half  of  the  anterior  abdominal  wall  with  the  hernial  regions  as  seen  from  within  and  above. 
At  the  site  of  the  femoral  ring  is  the  sac  of  a  femoral  hernia.  The  interior  inguinal  fossa  is  limited  internally  by 
a  sharply  bordered  fold  (falx  inguinalis),  which  belongs  to  the  transversalis  abdominis  muscle.  (Frozen  formalin  pre- 
paration.) 


orifice  of  the  inguinal  canal  is  known  as  the  internal  abdominal  ring  in  contradistinction  to  the 
external  orifice,  which  is  known  as  the  external  abdominal  ring.  At  the  internal  ring  the  sper- 
matic vessels  (the  spermatic  artery  from  the  abdominal  aorta  and  the  spermatic  veins)  also  dis- 
appear in  company  with  the  vas  deferens.  The  peritoneum  closes  this  internal  abdominal  ring 
and  forms  the  external  inguinal  fossa  (fovea  inguinalis  lateralis),  which  is  situated  to  the  outer 
side  of  the  deep  epigastric  artery.  While  this  fossa  corresponds  to  the  abdominal  orifice  of  the 
inguinal  canal,  the  middle  inguinal  fossa  (fovea  inguinalis  medialis),  situated  between  the  plica 
epigastrica  and  the  plica  umbilicalis  lateralis,  lies  directly  beneath  the  external  opening  of  the 
inguinal  canal.     Still  further  to  the  inner  side  is  the  fovea  supravesical,  situated  between  the 


Fig.  56. 


Peritoneum 
M.  iliacus 

Anterior  crural  nerve. 

M.  psoas 

Deep  epigastric  artery  and  veins 

External  inguinal  fossa 

Epigastric  fold 

External  umbilical  ligament 

Middle  inguinal  fossa 

Middle  umbilical  ligament 

(urachus) 

Femoral  fossa'' 

Vas  deferens 


Middle  umbilical  fold 

Anterior  superior  spine 

of  ilium 
External  umbilical  fold 

Spermatic  artery  and  vein 
Falx  inguinalis 
Femoral  artery  and  vein 
Poupart's  ligament 
Iliac  bone 
Supravesical  fossa 
(internal  inguinal  fossa) 


Obturator  foramen     — 


Vas  deferens 
Tuberosity  of  ischium 


Urinary  bladder 


F'g-  57- 


Umbiliculus 

Skin 
Panniculus  adiposus 


Anterior  layer  of  — 
sheath   of  rectus 

M.   rectus  -- 


Deep  epigasl.  artery 

Transversalis  fascia  " 
Peritoneum  ■ 


M.   rectus ft  , 


Direct  inguinal  hernia 


Aponeurosis  of  ext. 
oblique  muscle 


M.  obliq.  int.  abd. 
M,  transvers.  abd. 


Transversalis  facia 
Peritoneum 

■Sigmoid  colon 

■  External  umbilic.  lig. 
(obliterated  hypogast.  art.) 
Middle  umbilical  lig. 
(urachus) 


-Urinary  bladder 


Spermatic  cord 


"Penis 


THE   PERITONEUM.  12t- 

plica  umbilicalis  lateralis  and  the  plica  umbilicalis  media.  The  three  foveas  which  have  just 
been  mentioned  are  above  Poupart's  ligament  and  may  be  seen  and  felt  upon  the  inner  surface 
of  the  anterior  abdominal  wall.  The  femoral  fossa  (fovea  femoralis)  is  below  Poupart's  ligament, 
opposite  to  the  fovea  inguinalis  medialis.  In  this  situation  the  peritoneum  covers  the  femoral 
ring  (annulus  femoralis),  which  is  also  called  the  internal  femoral  ring  (see  page  143  and  Figs. 
56,  58,  and  76).  With  the  aid  of  Fig.  56  the  reader  should  firmly  fix  in  his  mind  that  inguinal 
hernias  pass  out  above  Poupart's  ligament,  while  the  femoral  variety  makes  its  exit  below  this 
structure.  The  external  inguinal  fossa  gives  passage  to  the  external  oblique  or  indirect  inguinal 
hernia ;  the  internal  inguinal  fossa  is  the  site  of  the  internal  or  direct  inguinal  hernia.  The  very 
rare  internal  oblique  inguinal  hernia  (hernia  inguinalis  obliqua  medialis)  passes  out  through  the 
fovea  supravesicalis. 

THE  PERITONEUM. 

The  peritoneum  is  attached  to  the  inner  surface  of  the  abdominal  wall  by  loose  connective 
tissue  and  is  consequently  more  or  less  movable.  It  is  also  very  elastic,  as  may  be  seen  after 
recovery  from  ascites,  pregnancy,  or  tumors,  where  the  previously  distended  peritoneum  forms 
no  persisting  folds.  The  relation  of  the  peritoneum  to  the  viscera  is  similar  to  that  of  the  pleura 
to  the  lungs,  so  that  we  differentiate  a  parietal  layer,  covering  the  inner  surface  of  the  abdominal 
wall,  and  a  visceral  layer,  reflected  over  the  abdominal  organs.  If  we  imagine  that  most  of  the 
viscera  grow  into  the  peritoneal  cavity  from  behind,  it  will  be  apparent  that  they  are  connected 
to  the  posterior  abdominal  wall  by  reflections  of  the  peritoneum.  These  peritoneal  duplicatures 
are  known  in  general  as  peritoneal  ligaments;  that  of  the  intestine  is  called  the  mesentery,  while 
that  of  the  colon  is  the  mesocolon.  If  the  ligament  is  very  long,  the  organ  is  naturally  more  mov- 
able (the  mesentery  of  the  intestine,  for  example);  while  if  it  is  short  and  broad,  the  organ  is 
more  fixed  (the  coronary  ligament  of  the  liver).  The  organs  are  also  connected  with  each  other 
by  similar  peritoneal  ligaments  or  duplicatures  (liver  and  stomach,  stomach  and  colon).  If  the 
viscera  remain  against  the  posterior  abdominal  wall  so  that  only  a  small  portion  of  their  ventral 
surfaces  possesses  a  peritoneal  covering,  we  say  that  they  are  situated  outside  of  the  peritoneal 
cavity  (the  pancreas  and  the  kidneys).  This  relation  and  the  following  ones  will  be  made  clearer 
by  a  study  of  Fig.  59. 

If  we  open  the  peritoneal  cavity  by  an  incision  in  the  linea  alba,  we  find  behind  the  ligamentum 
duodenale*  (passing  from  the  inferior  surface  of  the  liver  to  the  duodenum)  a  foramen  which  is 
called  the  foramen  epiploicum,  or  foramen  of  Winslow.  This  leads  us  into  a  second  space,  sepa- 
rated from  the  general  peritoneal  cavity  in  its  course  of  development,  which  is  known  as  the 
bursa  omentalis  or  lesser  peritoneal  cavity,  and  extends  downward  behind  the  stomach,  originally 
as  far  as  the  free  border  of  the  great  omentum.  In  rare  cases  viscera  (intestines)  have  been  found 
projecting  through  a  dilated  foramen  of  Winslow  into  the  lesser  peritoneal  cavity  (a  variety  of 
internal  hernia),  and  in  such  cases  symptoms  of  strangulation  may  be  produced  by  the  constric- 
tion at  the  foramen  of  Winslow.  The  great  rarity  of  this  hernia  is  due  to  the  protected  position 
of  the  foramen  and  to  the  overlying  liver. 

Under  normal  conditions  the  abdominal  viscera  fill  the  abdominal  cavity  in  such  a  manner 

*  Better  known  to  American  and  English  readers  as  the  right  free  edge  of  the  gastro-hepatic  omentum. 


126  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  59. — First  diagram  for  the  representation  of  the  peritoneum.  The  bursa  omentalis  is  outlined  in  red,  the  re- 
maining portion  of  the  peritoneal  cavity  in  blue. 

Fig.  60. — Second  diagram  for  the  representation  of  the  peritoneum.  As  in  Fig.  59,  the  bursa  omentalis  is  outlined 
in  red. 

that  they  are  separated  only  by  capillary  spaces;  complementary  spaces  or  sinuses,  similar  to 
those  found  in  the  pleural  cavities,  do  not  exist.  These  capillary  spaces  between  the  viscera 
are  filled  normally  by  a  sparing  amount  of  peritoneal  fluid ;  a  pathologic  increase  in  the  amount 
of  this  fluid  is  known  as  abdominal  dropsy  or  ascites. 

In  the  median  line  above  the  navel  (Fig.  60)  the  parietal  layer  of  the  peritoneum  passes 
from  the  inner  surface  of  the  anterior  abdominal  wall  to  the  under  surface  of  the  diaphragm, 
which  it  covers  as  far  as  the  openings  for  the  esophagus  and  inferior  vena  cava.  Since  nothing 
but  the  thin  lamina  of  the  diaphragm  separates  the  peritoneum  from  the  pleura  and  pericardium, 
it  will  be  understood  that  an  inflammation  originating  in  the  peritoneum  may  pass  through  the 
diaphragm  and  extend  to  the  pleura  and  pericardium.  In  the  median  plane  the  peritoneum  above 
the  navel,  between  the  inner  surface  of  the  anterior  abdominal  wall  and  the  inferior  surface  of 
the  liver,  forms  the  falciform  or  suspensory  ligament  of  the  liver  (ligamentum  falciforme  hepatis), 
in  the  free  posterior  margin  of  which  is  situated  the  round  ligament  (ligamentum  teres),  originally 
the  umbilical  vein.  From  the  inferior  surface  of  the  diaphragm  the  peritoneum  passes  to  the 
posterior  surface  of  the  liver,  which  is  in  relation  with  the  posterior  abdominal  wall,  and  thus 
forms  the  upper  layer  of  the  broad  coronary  ligament  of  the  liver  (ligamentum  coronarium  hepatis). 
The  right  and  left  free  margins  of  this  ligament  are  known  as  the  ligamenta  triangularia*  From 
the  upper  surface  of  the  liver  the  visceral  peritoneum  is  reflected  about  the  free  anterior  margin 
of  the  viscus  to  the  inferior  surface,  which  it  covers  as  far  as  the  porta  hepatis,  from  which  it 
passes  to  the  lesser  curvature  of  the  stomach  and  to  the  upper  portion  of  the  duodenum,  forming 
the  anterior  layer  of  the  lesser  or  gastrohepatic  omentum  (ligamentum  hepatogastricum  and  liga- 
mentum hepatoduodenale).  It  then  covers  the  anterior  surface  of  the  stomach  and  reaches  the 
transverse  colon  in  front  of  the  greater  curvature.  From  the  transverse  colon  it  passes  down- 
ward as  the  anterior  layer  of  the  great  or  gastrocolic  omentum,  then  upward  from  the  free  margin 
of  the  great  omentum  to  the  transverse  colon,  from  which  it  passes  backward  to  the  posterior 
abdominal  wall,  forming  the  lower  layer  of  the  transverse  mesocolon.  Upon  reaching  the  pos- 
terior abdominal  wall,  the  peritoneum  covers  the  anterior  surface  of  the  ascending  portion  of  the 
duodenum.  Below  this  region  the  peritoneum  is  reflected  from  the  vertebral  column  about  the 
small  intestine,  forming  both  layers  of  the  mesentery.  The  attachment  of  the  mesentery  to  the 
posterior  abdominal  wall,  the  radix  mesenterii,  extends  downward  from  the  left  border  of  the 
second  lumbar  vertebra  to  the  right  sacroiliac  articulation.  As  a  result  of  this  oblique  insertion, 
extravasations  of  blood  originating  upon  the  right  side  of  the  mesentery  pass  into  the  right  iliac 
region,  while  those  upon  the  left  side  find  an  open  path  to  the  pelvic  cavity.  The  longest  portion 
of  the  mesentery  is  situated  about  twenty  centimeters  above  the  appendix,  and  this  portion  of 
the  ileum  is  consequently  the  one  most  frequently  found  in  inguinal  hernia.  [According  to  Treves, 
the  longest  part  of  the  mesentery  is  found  at  two  points,  one  six,  the  other  eleven  feet  from  the 
duodenum.     The  folds  of  small  intestine  corresponding  to  these  may  and  often  do  reach  the 

*  The  right  and  left  lateral  ligaments  of  the  liver. 


Liver 


Coronary  ligament  of  liver  *"--___ 


Foramen  of  Winslow 
Pancreas 


Transverse  mesocolon 
Colon 


Mesentery 
Jejunum 


Coronary  ligament   of  liver 


Lesser  omentum 
Lesser  peritoneal  cavity 


Pancreas 
Vertebral  canal 

Duodenum 


Mesentery 


Rectum  _ 


Great  omentum 


F'g-  59- 


Visceral  peritoneum 

Stomach 

Parietal  peritoneum 

Peritoneal  cavity 


Fig.  60. 


Diaphragm 

Liver 

Parietal  peritoneum 
Visceral  peritoneum 

-Stomach 

Transverse  mesocolon 
Colon 

*-  Great  omentum 
-Small  intestine 


.Urinary  bladder 

Symphysis 

Prostatic  portion  of  urethra 
Prostate  gland 
Postpubic  urethral  curve 
-Subpubic  urethral  curve 

-Epididymis 

Tunica  vaginalis  testis 
Testis 


THE   PERITONEUM.  i2J 

pelvis.  The  attachment  of  the  mesentery  for  the  lower  end  of  the  ileum  is  placed  so  much  nearer 
the  pelvic  cavity  that  this  portion  of  the  bowel,  even  with  a  shorter  mesentery,  occupies  the  pelvis 
and  is  often  found  in  an  inguinal  or  femoral  hernia.— Ed.]  After  partly  surrounding  the  pelvic 
viscera  (see  page  147  for  detailed  description),  the  peritoneum  passes  from  the  upper  surface 
of  the  bladder  to  the  inner  surface  of  the  anterior  abdominal  wall  and  upward  to  the  umbilicus. 

Upon  the  right  side  the  peritoneum  passes  from  the  porta  hepatis  to  the  superior  portion 
of  the  duodenum  and  forms  the  anterior  layer  of  the  ligamentum  hepatoduodenale.  There  is  no 
sharp  line  of  demarcation  between  this  ligament  and  the  ligamentum  hepatogastricum,  but  the 
ligamentum  hepatoduodenale  is  thicker  and  contains  the  ductus  choledochus  in  its  right  free  bor- 
der. Further  to  the  left  the  hepatic  artery  is  enclosed  between  the  layers  of  the  same  ligament, 
while  the  portal  vein  passes  to  the  liver  between  and  somewhat  behind  the  artery  and  duct.  We 
will  now  trace  the  peritoneum  through  the  foramen  of  Winslow  into  the  bursa  omentalis.  This 
posterior  layer  of  the  peritoneum  is  indicated  in  the  diagrammatic  drawing  (Fig.  60)  by  a  red 
line.  It  first  forms  the  posterior  layer  of  the  gastrohepatic  omentum,  then  covers  the  posterior 
surface  of  the  stomach,  and  passes  from  the  greater  curvature  to  the  transverse  colon  as  the  pos- 
terior layer  of  the  narrow  ligamentum  gastrocolicum.  As  a  rule,  the  bursa  omentalis  does  not 
extend  into  the  great  omentum  in  adult  life;  this  portion  of  the  peritoneum  is  consequently 
represented  in  Fig.  60  by  a  red  dotted  line.  After  the  disappearance  of  the  lumen  of  the  bursa 
omentalis  the  anterior  and  posterior  layers  of  the  great  omentum  become  adherent  and  the  pos- 
terior layer  also  adheres  to  the  anterior  surface  of  the  transverse  colon ;  in  this  manner  the  liga- 
mentum gastrocolicum  is  formed  (compare  Fig.  59  with  Fig.  60).  At  the  bottom  of  the  bursa 
omentalis  the  peritoneum  forms  the  upper  layer  of  the  transverse  mesocolon;  it  then  passes  to 
the  vertebral  column,  covers  the  anterior  surface  of  the  pancreas,  forms  the  inferior  layer  of  the 
ligamentum  coronarium  hepatis,  and  is  finally  reflected  over  the  caudate  lobe  of  the  liver.  If  the 
liver  is  displaced  upward,  the  caudate  lobe  may  therefore  be  seen  lying  in  the  bursa  omentalis, 
beneath  the  gastrohepatic  omentum;  it  is  also  easy  to  see  the  pancreas  through  the  same  omentum 
in  the  posterior  portion  of  the  bursa  omentalis  by  displacing  the  stomach  somewhat  downward. 
The  upper  portion  of  the  duodenum  also  receives  a  peritoneal  covering  from  the  bursa  omentalis 
which  extends  toward  the  left  as  far  as  the  kidney  and  the  spleen,  where  it  forms  the  posterior 
layer  of  the  ligamentum  gaslrolienale*  which  connects  the  stomach  with  the  spleen  (see  page 
133).  In  Fig.  60  it  is  clearly  shown  that,  in  addition  to  the  foramen  of  Winslow,  the  lesser  peri- 
toneal cavity  may  be  opened  from  the  front  in  three  places:  (1)  Through  the  lesser  omentum; 
(2)  through  the  ligamentum  gastrocolicum;  and  (3)  through  the  transverse  mesocolon.  Upon 
the  right  side  the  peritoneum  passes  from  the  inferior  surface  of  the  liver  to  the  anterior  surface 
of  the  right  kidney;  it  then  runs  to  the  hepatic  flexure  of  the  colon  and  the  flexura  duodeni  supe- 
rior and  is  reflected  over  the  anterior  surface  and  sides  of  the  ascending  colon,  so  that  this  portion 
of  the  intestine  has  a  comparatively  broad  attachment  to  the  posterior  abdominal  wall.  In  the 
right  iliac  fossa  the  cecum  with  the  processus  vermiformis,  which  possesses  its  own  mesenteriolum, 
is  usually  completely  surrounded  by  peritoneum. 

Upon  the  left  side  the  parietal  peritoneum  is  reflected  from  the  inferior  surface  of  the  duo- 
denum to  the  stomach,  from  which  it  passes  to  the  spleen,  forming  the  ligamentum  phrenico- 

*GastrospIenic  omentum. 


128  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

PLATE  14. 

The  position  of  the  abdominal  viscera  of  a  boy.  Anterior  view.  The  lungs,  the  heart,  and  the  anterior  half  of  the 
diaphragm  have  been  removed;  the  small  intestine  has  been  cut  away  at  the  root  of  the  mesentery.  From  an  accurate 
Leipzig  model  made  from  an  original  dissection  (His). 

PLATE  15. 
The  position  of  the  kidneys,  pancreas,  spleen,  duodenum,  and  colon  as  seen  after  the  removal  of  the  liver,  stomach, 
and  transverse  colon.     From  the  model  of  Plate  14. 

lienale.  The  spleen  is  almost  completely  enveloped  by  the  peritoneum,  which  passes  back  to  the 
stomach  as  the  anterior  layer  of  the  ligamentum  gastrolienale.  At  the  inferior  pole  of  the  spleen 
the  ligamentum  phrenicolicum  passes  from  the  diaphragm  to  the  splenic  flexure  of  the  colon; 
this  is  the  ligament  which  supports  the  spleen  from  below.  After  covering  the  splenic  flexure 
of  the  colon,  the  peritoneum  passes  to  the  descending  colon,  which,  like  the  ascending  colon, 
possesses  only  an  anterior  and  lateral  peritoneal  covering,  so  that  neither  colon  is  visible  from 
in  front  after  opening  the  peritoneal  cavity.  The  long  mesocolon  of  the  sigmoid  flexure  (S. 
romanum),  on  the  contrary,  permits  a  wider  range  of  motion,  so  that  this  portion  of  the  intestine 
is  often  found  in  the  dead  subject  to  the  right  of  the  median  line. 

THE  CONTENTS  OF  THE  ABDOMEN. 

The  Stomach. — The  stomach  is  situated  in  the  epigastrium  and  the  left  hypochondriac 
region  in  such  a  manner  that  only  one-sixth  of  the  viscus  is  to  the  right  of  the  median  line.  The 
fundus  of  the  stomach  touches  the  diaphragm  (Fig.  49)  and  borders  indirectly  upon  the  heart 
and  the  left  lung;  this  partly  explains  the  increased  cardiac  activity  and  accelerated  respiration 
which  are  produced  by  the  pressure  of  a  full  stomach.  A  large  portion  of  the  anterior  gastric 
surface  is  covered  by  the  liver.  Toward  the  left,  the  fundus  is  in  relation  with  the  concave  fades 
gastrica  of  the  spleen  (Plates  11,  13,  14,  15,  and  16). 

The  cardia  lies  to  the  left  of  the  median  line  at  the  level  of  the  eleventh  dorsal  vertebra  and 
at  quite  a  distance  (about  12  centimeters  dorsalward)  from  the  inner  surface  of  the  anterior 
abdominal  wall  (Plate  17).  When  projected  upon  the  anterior  surface  of  the  body,  the  cardia 
is  situated  one  fingerbreadth  below  the  sternal  attachment  of  the  left  seventh  costal  cartilage. 

The  pylorus  is  below  and  in  front  of  the  cardia  (Plate  17);  it  lies  to  the  right  of  the  median 
line  at  the  level  of  the  body  of  the  first  lumbar  vertebra ;  in  the  right  sternal  line  this  point  corre- 
sponds to  the  level  of  the  anterior  extremity  of  the  ninth  costal  cartilage.  From  the  relative  posi- 
tion of  the  cardia  and  pylorus  it  will  be  seen  that  the  lesser  curvature  of  the  stomach  pursues 
more  of  a  vertical  than  of  a  horizontal  direction.  The  greater  curvature,  the  lower  limit  of  the 
normal  stomach,  reaches  to  the  transverse  line  connecting  the  lowest  points  of  the  ninth  or  tenth 
ribs  (Plate  n);  it  consequently  does  not  extend  to  the  transverse  line  connecting  the  lowest  points 
of  the  inferior  aperture  of  the  thorax.  In  this  line  is  found  the  transverse  colon,  which  borders 
upon  the  greater  curvature  (Plate  11).  [The  pyloric  portion  of  the  stomach  is  bisected  by  a. 
horizontal  plane,  the  transpyloric,  which  passes  through  the  abdomen  midway  between  the  supra- 
sternal notch  and  the  pubic  symphysis. — Ed.] 

The  anterior  surface  of  the  stomach  below  the  lesser  curvature  is  covered  by  the  left,  and 
also  by  a  part  of  the  right  lobe  of  the  liver.     In  the  epigastrium,  below  the  xiphoid  process,  the 


14 


Gl«ndula-rtjw«*$d» 

Scalenus  antics  rn.. 

Subclavian  v. 

First  rib 


Mi 


I  larynx 

Internal  jugular  v. 
•  Common  carotid  artery 

.  I  .eft  innominate  v. 
1'ccioralis  major  m. 
.  IVloraUs  minor  m. 

Thoracic  duct 

A/\gos  minor  v. 


Insertion  of  falciform 
ligament 


Gallbladder- 


Ascending  colon. 
Root  of  mesentery , 


Descending  colon 


Cecum. 


Sigmoid  colon 


Rectum 


1 1 


Th 
region  i 

fundus 
and  tht 

which  . 


znvnc.l 

.1  u.liiyiit  li.niiinl 

Mini.  [niDi/'.'j  nomtnoD 

v    )li;nifiK)Min  lloJ  • 

■ 
.rn  loniin  ail 

uuL>  jiaBTO.riT  - 
.v  loni/n  <soms/.  - 


zirgsrfqoea 

mjjtivuliii.id. 


g  me; 


:ONTEN  ABDOr 

li.t  Jo  ni.in-v.nl  , 

«A.- The  st 


inner  th;i 
c  h  touches  !;'"  '•'  • 
ig;  this  partly 
■ 

ard  the  lei 
bwapU /  t      an 


.rn  zii  ji 


.  n-4<  ■  j  gntbd 


iii.l'ij  biornjjk: 


mulnSl 


Tab.K. 


Glandula  thyreoidea 

M.  scalenus  anterior 

V.  subclavia 

Costa  I 


V.  azygos_ 
Costae 
Mm.  inter costales ---v;;; "  \ 
V.  cava  inf. ■ 


Vesica  fellea 


Colon  ascendens 


Radix  mesenterii 


Coecum 


Larynx 

V.  jugularis  interna 
A.  carotis  communis 

V.  anonyma  sin. 
M.  pectoralis  major 
M.  pectoralis  minor 
Ductus  thoracicus 
-V.  hemiazygos 

Aorta  descendens 
Oesophagus 

Diaphragma 

■ 

Insertio  ligamenti  falciformis 

Ventricuk 

Colon  descendens 

^  Colon  sigmoideum 

-Rectum 


PLATE    36 


ftartcrvatrco  - 
ctt*ocferta/i»  art 


J~7</~* r/ues,c/ite-7'lc  art} 


Af.  CoJi/i.  ad  Ttatu  ra  m  del. 


[      ^  ms* 


**L- 


r^ 


Internal  jugular  vein 

Common  carotM  artery 

Subclavian  vein 

First  rib  ■ 

Thoracic  duct 

Azygos  major  vein  • 


Foram* 


oramen  vena;  cava? 


Right  suprarenal  gland  , 


Descending  portion  of  duodenum- 
Right  kidney. 


Ascending  portion  of  duodenum. 
Ascending  colon 

Root  of  mesentery . 


Cecum  , 


V 


'Larynx 


15 


Teoidea 


-Thyroid  gland 

■  Scalenus  amicus  m. 

—Left  innominate  veto 
•Pectoralis  minor  muscle 

-Pectoralis  major  muscle 


■Ribs 
Azygos  minor  vein 

Intercostal  muscles 
.Descending  aorta 
•  Esophagus 

.Gastric  surface  of  spleen 
.Left  suprarenal  gland 
.Left  kidney 

.Duodenojejunal  flexure 

.  Superior  mesenteric  artery 
.Superior  mesenteric  vein 
.Inferior  mesenteric  artery 
.  Descending  colon 


•  Sigmoid  flexure  of  colon 


or 


XIIT16.I" 


basis  bioT{riT- 
.m  2U)iJnc  aunskjZ 


am  •jiBaiftionni  rt*I. 
3l3?jjm  lonrm  eibiioJasI 

slDaum  -»'[Brn  silBioml 

fifl 
nir/  lonirr 

soloaum  lB)»>)Tj)nI 

2U8Giiqoa3 

basis  IsaMBiqua  rim 
X'mbii  Afl 

nuxoft  li;nu(-nor 

ni-r/  smlnvirti  wttfqH 

i(i9JTfi  Dnalnawm  loivjinl 

ooioj  gaibiU3B9Cl 

aoio3  k>  3iur>Ft  hioaisi^ 


mutij/1 


^ 


niov  ir,Iu3U(  bm-nlnl 
bouibkk) 


•  in**)! 


bads  l6rf'i8T>1u*  ni 


in  tj«-j<  I 


Jtf  /Ti«**.  «*  »•«/■*<  /•« ' 


Tab.  1.5. 


V.  jugularis  interna 

A.  carotis  communis 

V.  subclavia 

Costa  I 

Ductus  thoracicus 

V.  azygos 


Foramen  venae  cavae 


Glandula  suprarenalis  dex. 

Pars  descendens  duodeni 
Ren  dexter 


Pars  ascendens  duodeni 
Colon  ascendens 

Radix  mesenterii 
Coecum 


Larynx 

fc — Glandula  thyreoidea 
— -   M.  scalenus  anterior 

r- -  V.  anonyma  sin. 
M.  pectoralis  minor 

M.  pectoralis  major 

Costae 

V.  hemiazygos 

Mm.  intercostales 
Aorta  descendens 
Oesophagus 

Facies  gastiica  lienis 
Glandula  suprarenalis  sin. 
Ren  sinister 

Flexura  duodenojejunalis 

A.  mesenterica  sup. 
V.  mesenterica  sup. 
A.  mesenterica  inf. 

Colon  descendens 
Colon  sigmoideum 


Rectum 


=>LATE    35 


//Tmercrz— 
Seric  aert. 


M.Coftnr<zal rtatisrirm.  del. 


THE  CONTENTS   OF   THE  ABDOMEN.  1 29 

stomach  is  consequently  not  in  immediate  contact  with  the  anterior  abdominal  wall  (Plate  11); 
somewhat  downward  and  to  the  left,  however,  there  is  a  typically  formed  triangular  area  of  the 
gastric  surface  which  rests  against  the  inner  surface  of  the  abdominal  wall.  It  is  bounded  to  the 
right  by  the  inferior  margin  of  the  liver,  to  the  left  by  the  eighth  to  the  tenth  costal  cartilages,  and 
below  by  the  transverse  colon.  It  is  in  this  situation  that  gastrotomy  may  most  easily  be  per- 
formed for  the  establishment  of  a  fistula  or  for  the  removal  of  a  foreign  body.  Beneath  the  costal 
margin  in  the  left  hypochondriac  region  the  stomach  is  covered  not  only  by  the  ribs  and  intercostal 
muscles,  but  also  by  the  left  lung,  by  the  left  pleural  cavity,  and  by  the  diaphragm,  so  that  pene- 
trating wounds  in  this  region  may  injure  the  pleura,  the  lung,  and  the  stomach,  and  the  gastric 
contents  may  escape  into  the  pleural  cavity.  The  so-called  space  0}  Traube  is  situated  in  the  left 
hypochondriac  region  and  represents  that  portion  of  the  stomach  which  is  not  covered  by  the 
neighboring  viscera  (Plate  13,  left  illustration,  and  Plate  11).  It  is  bounded  above  and  to 
the  left  by  the  inferior  margin  of  the  left  lung,  above  and  to  the  right  by  the  inferior  margin 
of  the  left  lobe  of  the  liver,  below  and  to  the  right  by  the  costal  margin,  and  posteriorly  and 
to  the  left  by  the  spleen. 

The  posterior  surface  of  the  stomach  borders  upon  the  bursa  omentalis  (Figs.  60  and  62) 
which  separates  it  from  the  anterior  surface  of  the  pancreas,  the  facies  gastrica  of  the  spleen,  the 
duodenojejunal  flexure,  and  the  upper  portion  of  the  anterior  surface  of  the  kidney. 

For  clinical  purposes  it  is  important  to  remember  that  the  normal  stomach  is  separated 
anteriorly  and  posteriorly  from  the  neighboring  organs  by  capillar}7  spaces,  but  in  such  a  manner 
that  a  direct  relation  and  contact  is  a  possible  and  more  or  less  frequent  occurrence  during  life. 
In  this  manner  may  be  explained  the  adhesions  between  the  stomach  and  neighboring  organs  and 
their  manifold  sequelae  in  cases  of  gastric  ulcer.  After  adhesions  with  the  pancreas  and  to  the 
splenic  vessels  running  along  its  upper  border,  a  fatal  hematemesis  may  occur  from  the  perfora- 
tion of  the  splenic  artery  by  a  gastric  ulcer.  A  similar  ulcer  may  become  adherent  to  the  trans- 
verse colon  and  perforate  into  this  portion  of  the  intestine,  so  that  there  is  a  direct  communication 
between  the  stomach  and  the  colon;  the  stomach  may  adhere  to  the  diaphragm  and  the  gastric 
ulcer  may  perforate  into  the  pleural  or  into  the  pericardial  cavity.  If  the  lung  has  become  adhe- 
rent to  the  upper  surface  of  the  diaphragm,  the  inflammatory  process  will  spread  to  the  lungs 
and  the  bronchi  and  the  gastric  contents  may  gain  access  to  the  bronchi  and  be  coughed  up.  If 
the  anterior  surface  of  the  stomach  contracts  adhesions  with  the  inner  surface  of  the  abdominal 
wall,  it  is  possible  for  the  inflammation  to  extend  to  the  abdominal  wall  and  end  in  external  per- 
foration. 

The  arteries  0}  the  stomach  all  arise  from  the  celiac  axis,  the  first  of  the  three  single  branches 
of  the  abdominal  aorta.  (Where  does  the  abdominal  aorta  begin  and  where  does  it  end  ?  What 
are  the  names  of  the  four  paired  parietal  branches  and  of  the  three  single  and  three  paired  vis- 
ceral branches  ?)  The  celiac  axis  arises  from  the  anterior  surface  of  the  aorta  just  below  the 
aortic  opening  in  the  diaphragm  (Fig.  61)  and  immediately  divides  into  three  branches,  the  gas- 
tric, the  hepatic,  and  the  splenic  arteries.  The  gastric  artery  (A.  gastrica  sinistra)  runs  from  the 
left  to  the  right  along  the  lesser  curvature  at  the  attachment  of  the  lesser  omentum.  The  hepatic 
artery  gives  off  the  second  of  the  two  arteries  of  the  lesser  curvature,  the  pyloric  (A.  gastrica 
dextra),  which  passes  to  the  left  from  the  pylorus  and  anastomoses  with  the  gastric  artery.  The 
9 


130  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

PLATE  16. 

The  position  of  the  thymus  gland,  heart,  liver,  stomach,  spleen,  and  intestines  of  a  fifteen-year-old  girl  as  seen 
from  the  left.     The  left  lung  has  been  removed.     From  a  Leipzig  model  from  nature  (His). 

hepatic  artery  also  supplies  the  liver  as  it  runs  in  the  ligamentum  hepatoduodenal*  as  the  arteria 
hepatica  propria  and  enters  the  liver  at  the  transverse  fissure.  The  third  branch  of  the  hepatic 
artery,  the  gastroduodenal,  divides  into  the  superior  pancreatico-duodenal  artery  for  the  head  of 
the  pancreas  and  the  gastro-epiploica  dextra,  which  passes  to  the  left  along  the  greater  curvature 
of  the  stomach.  The  splenic  artery,  the  third  terminal  division  of  the  celiac  axis,  runs  along  the 
upper  margin  of  the  pancreas  behind  the  stomach  (see  page  129  and  Fig.  61)  to  the  hilus  of  the 
spleen  and  gives  off  the  gastro-epiploica  sinistra,  which  runs  to  the  right  along  the  greater  cur- 
vature, supplying  the  stomach  and  the  great  omentum  and  anastomosing  withthe  gastro- 
epiploica  dextra. 

The  veins  of  the  stomach  are  the  gastro-epiploica  sinistra  and  dextra,  running  along  the 
greater  curvature,  and  the  vena  coronaria  ventriculi  along  the  lesser  one.  At  the  cardia,  the 
coronary  vein  anastomoses  with  the  esophageal  veins,  and  through  these  with  the  vena  azygos 
major  (see  page  123  and  Fig.  55).  All  of  the  gastric  veins  empty  into  the  portal  system.  The 
pneumogastric  nerves  have  been  described  upon  page  116;  the  left  pneumogastric  passes  chiefly 
to  the  anterior  surface,  while  the  right  one  supplies  the  posterior  surface  of  the  stomach. 

The  Liver. — The  relations  of  the  liver,  the  largest  organ  of  the  abdominal  cavity,  are  of 
particular  importance  to  the  physician  on  account  of  the  many  diseases  of  this  viscus,  of  which 
those  of  the  biliary  passages  in  particular  are  now  treated  by  surgical  measures.  The  organ  lies 
chiefly  in  the  right  hypochondrium,  but  also  extends  across  the  epigastrium  into  the  left  hypo- 
chondriac region  (Plates  11-14  and  16). 

The  upper  convex  surface,  divided  into  the  right  and  the  left  lobe  by  the  falciform  ligament, 
is  in  immediate  relation  with  the  diaphragm  (Plates  10,  13,  and  14,  and  Figs.  49  and  62).  Since 
this  structure  projects  upward  into  the  thorax,  the  greater  portion  of  the  liver  is  surrounded  by 
the  ribs,  but  the  right  pleural  sac  (Figs.  49  and  62  and  Plate  14)  is  interposed  between  the  liver 
and  the  thoracic  wall,  so  that  penetrating  wounds  which  pass  between  the  ribs  and  involve  the 
liver,  as  a  rule,  open  this  pleural  cavity.  The  upper  surface  of  the  liver  is  not  only  in  relation 
with  the  right  lung,  the  diaphragm  being  interposed,  but  also  with  the  heart,  with  the  pericardial 
cavity  (Fig.  62),  and  with  a  portion  of  the  left  lung.  Hepatic  abscesses  may  consequently  per- 
forate the  diaphragm  and  rupture  into  the  pleural  cavities  or  into  the  pericardium.  Such  an 
occurrence  is,  of  course,  preceded  by  peritoneal  adhesions  between  the  upper  surface  of  the  liver 
and  the  lower  surface  of  the  diaphragm.  An  abscess  of  the  liver  may  also  perforate  into  a  bron- 
chus, so  that  pus  from  the  liver  may  be  expectorated ;  in  such  a  case,  the  inferior  surface  of  the 
lung  must  have  contracted  adhesions  to  the  diaphragm.  If  one  of  the  pleural  cavities  becomes 
filled  with  an  exudate  or  with  air  (pneumothorax),  the  diaphragm  and  the  liver  must  be  dis- 
placed downward. 

The  details  of  the  inferior  surface  of  the  liver  are  very  peculiar  and  best  fixed  upon  the  mind 
when  the  organ  has  been  left  in  place.     While  the  inferior  surface  of  a  liver  which  has  been 

*  Free  edge  of  lesser  omentum. 


GlanduldThyroid  gland 
Trachea 

Left  innominate  vein 
First  rib 

Thymus 
Auricula     Left  auricle 


Right  ventricle. 


Diaphragm 
Lobus  Left  lobe  of  brer 

SeVenth  rib 
Stomach 


Small  intestine  and  oment 


Sigmoid  flexure  of  colon 

Lig.  ingTJ'  Poupart's  ligament 
Iliopsoas  muscle 

Femoral  rein 

Obturator  extern,  muscle 

Labium  majus 


16 


Fsophagus 

Left  subclavian  alters 
I-cft  common  carotid  a. 
Desomdinti  —  tmden.s 


Left  pulmonary  artery 
Left  bronchus 


Left  pulmonary  veins 

Left  ventricle5  sinister 

Pericardium 


Spleen 
Diiphragm 

Fleventh  rib 


Twelfth  rib 
Left  kidney 


Descending  colon 
Quadra  rus  lumborum  m. 


Pyriforrais 


Levator  ani 


*3° 


TOPOGR-A 


ncreatico 

"     ■  till'  It 


bosla  bioiyii'l 
ssifanT 

nijy  •ili;nim..nni  rtsj 


ig  baa  beti 

ar 

!,.(„,  )KI_ 

stomach.  I      '*>*  wiba'*i*1 1  ~"t- 

r  margin  ; 1  T 

n  and  gi  Tr"M  osaomiw,  «i*i ^_^hich  runs  V 

vature,  suppl  '"rfjn,,1^%1  and  Vhe   grmt   nmcfimm   ami   an — \ ****** 

,  earn  xTJ^iomliKj  rtaJ- 

epiploica  dex<  ^^  JbJ !_**»■*  *»;* 

The  *W«s  of  the  stonu^ijvy  thfe  gastro-eptploio  -.1  ann  "7 

greater  curvature,  and  the  v«w  co/wLr/n  vvntricu  t  i      ;g  the  lesser  *ne.     Al 
coronar  :iastomoses  with  the  esophageal  veins;;  and  through  th*e  with  : 

major  (see  page  123  and  Fig.  55).     All  of  the  gastric  veins  empty  into  uie  porTaT- 
pneumogastric  nerves  have  been  described  upon  page  no,   tlit  ltft.pneuK     ""'  *  *" lW 


to  the  anterior  surface,  w 


\      supplies  the  posterior  surfacd  of  the  stomach. 
'erf me  largest  or^tuj^ot  the  a|<!      11 


The  Liver.— The  rejfttjions^ 

particular  importance  to  t?    ph  V  account  of  the  many^^^^-L 

those  of  the  biliary  passagfe'^forticuIaJare  now  trea:  *  P^^moi^h 

chiefly  in  t»<Mi*am,  but  frlm  extends  acros 

chondria.  ■  i-M  and  1 

Th  no(.o  -JmJi         I      -  riSht  and  th^ lobe  by 

*  Kunodmrf  ,^  /     -         ^   IO'   *3'  ^^^^  F 

/  er  portion  of  t 

/  ^»-— —  /  n  the  1 

(  / 

/  > / biomsia 


Iciform  ; 

Mnce 


r.i'iioinv'I 


mi.  iola/vl , 


;>hragm 
occurrence  is,  of  coir 
and  the  lower  sur 
chus,  so  that  pus  i 
lung  mi; 
fille<i  with  at 

The  details 
when  the  organ  has 


.  tuyi  Ut 
______  n  .milM  TOlr.-mJdO 


.  iu[cm  rnuulcJ 


Tab. 16. 


Intestinum  tenue^ 
et  Omentum"""" '■■ 


Colon  sigmoideum 

Lig.  inguinale  (Pouparti) 
M.  iliopsoas 

V.  femoralis 
M.  obturator  ext. 


Oesophagus 
A.  subclavia  sin. 
A.  carotis  com.  sin. 
Aorta  descendens 

_.A.  pulmorialis  sin. 
.Bronchus  sinister 

Vv.  pulmonale*  sin. 
Ventriculus  sinister 

Pericardium 

Lien 
Diaphragma 

Costa  XI 

Costa  XII 
-Ren  sinister 

..Colon  descendens 
M.  quadratus  lumborum 


M.  piriformis 


M.  levator  ani. 


Labium  majus 


THE   CONTENTS   OF  THE   ABDOMEN.  I3I 

removed  from  the  body  is  usually  flattened,  on  account  of  the  doughy  consistency  of  the  viscus, 
the  study  of  a  liver  hardened  in  situ  is  most  instructive  (Fig.  63).  Particularlv  striking  is  the 
impressio  renalis  of  the  right  kidney,  and,  in  front  of  this,  the  impressio  colica  produced  by  the 
hepatic  flexure  of  the  colon.  The  duodenum,  the  pylorus,  and  the  stomach  are  responsible  for 
the  impressiones  duodenalis,  pylorica,  and  gastrica,  while  the  tuber  omentale  lies  above  the  lesser 
curvature  of  the  stomach  opposite  the  gastro-hepatic  omentum.  In  addition  to  these,  there  are 
the  impressio  suprarenalis  of  the  right  suprarenal  body,  the  impressio  oesophagea,  the  fossa  vena 
umbilicalis  (in  adult  life  containing  the  ligamentum  teres,  the  remains  of  the  umbilical  vein), 
and  the  fossa  vesica  fellece,  which  lodges  the  gall-bladder. 

At  the  porta  hepatis  the  artery  lies  to  the  left,  the  ductus  choledochus  to  the  right,  and  the 
portal  vein  behind  and  between  these  structures  (see  page  136  and  Fig.  64).  The  lobus  caudatus 
(Spigelii),  which  is  in  relation  with  the  bursa  omentalis,  together  with  the  inferior  vena  cava, 
borders  upon  the  vertebral  column  and  is  vertically  placed.  These  parts  are  in  relation  with 
the  so-called  posterior  surface  of  the  liver.  The  physician  directs  his  examination  of  the  liver 
chiefly  to  the  anterior  (inferior)  sharp  margin,  the  position  of  which  is  influenced  by  pathologic 
enlargements  or  diminutions  in  size  of  the  organ.  In  the  axillary  line  the  lower  margin  is  at  the 
level  of  the  eleventh  rib;  in  the  right  mammary  line  the  inferior  border  of  the  liver  leaves  the 
costal  margin,  passes  obliquely  upward  and  to  the  left,  crosses  the  median  line  midway  between 
the  navel  and  the  base  of  the  xiphoid  process,  and  reaches  the  left  costal  margin  in  the  para- 
sternal line.  It  will  be  observed  that  the  portion  of  the  liver  below  the  sternum  is  in  immediate 
contact  with  the  muscular  abdominal  wall  ("  scrobiculus  cordis,"  see  page  91).  The  gall- 
bladder projects  slightly  beyond  the  inferior  margin  of  the  liver  and  is  situated  in  the  right  para- 
sternal line,  a  fingerbreadth  to  the  inner  side  of  the  point  where  the  liver  extends  beyond  the 
costal  margin.     The  normal  liver  is  not  palpable  at  the  costal  margin  in  the  mammary  line. 

If  the  intestines  are  distended  with  an  abnormal  amount  of  gas  (meteorismus)  or  if  the  peri- 
toneal cavity  contains  an  excessive  quantity  of  fluid  (ascites),  the  liver  will  be  pushed  upward 
and  its  inferior  margin  will  be  correspondingly  displaced;  the  liver  will  also  press  upward  upon 
the  heart  and  lungs. 

The  gall-bladder  is  in  immediate  relation  with  that  portion  of  the  inner  surface  of  the  abdom- 
inal wall  which  has  just  been  indicated,  and  is  here  easily  accessible  to  the  surgeon.  It  may 
become  adherent  to  the  abdominal  wall  and,  after  inflammatory  processes,  gall-stones  may  pass 
through  the  abdominal  wall  so  that  a  biliary  fistula  is  formed  which  discharges  bile  externally. 
Inspection  of  the  inferior  surface  of  the  liver  and  of  the  depressions  in  the  vicinity  of  the  gall-blad- 
der (Fig.  63)  shows  that  gall-stones  or  pus  (empyema  of  the  gall-bladder)  may  pass  through  the 
wall  of  the  gall-bladder  into  the  duodenum,  into  the  colon,  into  the  stomach,  and  even  into  the 
pelvis  of  the  kidney.  Such  events  are  always  preceded  by  peritoneal  adhesions  between  the  gall- 
bladder and  the  affected  viscus. 

There  are  a  number  of  lymphatic  glands  in  the  transverse  fissure  (Fig.  64),  enlargements  of 
which  may  produce  disagreeable  consequences,  since  they  may  press  upon  the  common  or  hepatic 
duct,  causing  biliary  stasis  (and  even  death),  or  compress  the  vessels  and  lead  to  inflammation 
of  the  portal  vein  (pylephlebitis). 

[Several  other  points  with  reference  to  the  anatomy  of  the  liver  may  be  recalled  with 


132 


TOPOGRAPHIC   AND    APPLIED    ANATOMY. 


Fig.  6i  . — The  porta  hepatis,  the  pancreas,  the  duodenum,  the  kidneys,  the  spleen,  and  the  suprarenal  bodies  with  their 

vessels  (formalin  preparation). 

interest:  (i)  The  falciform  ligament,  which  is  attached  to  the  superior  surface,  does 
not  lie  in  the  median  sagittal  plane  of  the  body,  but  somewhat  to  the  right ;  it  may  hinder 
exploration  of  the  superior  surface  of  the  right  lobe  through  a  median  incision,  and  to 
secure  better  access  to  this  surface  it  may  be  necessary  to  cut  this  ligament;  correspond- 
ing as  it  does  to  the  umbilical  fissure,  it  serves  as  a  guide  to  the  latter  and  therefore 
to  the  gall-bladder,  which  lies,  of  course,  further  to  the  right.  (2)  Subphrenic  abscesses 
between  the  diaphragm  and  right  lobe,  and  abscesses  of  the  right  lobe  itself,  are  frequently  more 


Spinous  process  of 
vertebra 


Spinal  cord 


Body  of  vertebra 
Diaphragm 


Ascending  aorta  - 

Inferior  vena  cava  - 
Pylorus 
Pleural  cavity  " 


Liver 
Inferior  lobe  of  right 
lung 


Falciform  ligament 
of  liver 
Cavity  of  pericar- 
dium 


Sternum 


-  Latissimus  dorsi 
muscle 


•  —  Spleen 

Omental  bursa 


-  Pleural  cavity 

-  Teres  major  muscle 
—  Stomach 

Diaphragm 

Abdominal  cavity 

_  Lower  lobe  of  left 
lung 

—  Serratus  anticus  m. 

Pericardium 

Pleural  cavity 
Apex  of  the  heart 


Fig.  62. — A  cross-section  of  the  trunk  at  the  level  of  the  xiphoid  process  of  the  sternum. 


easily  and  safely  drained  by  removing  a  rib  and  crossing  the  pleural  cavity — transpleural  drain- 
age— than  by  the  abdominal  route.  Particularly  is  this  true  when  the  abscess  is  pointing  pos- 
teriorly and  has  not  caused  the  liver  to  project  far  beneath  the  costal  arch.  (3)  The  gall-bladder 
is  beneath  the  abdominal  wall  opposite  the  angle  between  the  outer  edge  of  the  rectus  and  the 
ninth  costal  cartilage,  where,  when  enlarged,  it  may  be  felt;  its  duct,  the  cystic,  is  tortuous,  which, 
together  with  the  arrangements  of  valves  of  mucous  membrane  in  the  calibre  of  the  duct,  prevents, 
as  a  rule,  its  exploration  with  a  probe  or  sound.  This  duct  joins  in  the  portal  fissure  with  the 
hepatic  duct  to  make  the  common  duct — ductus  communis  clioledochus.  The  common  duct  in 
the  first  portion  of  its  course  lies  in  the  right  edge  of  the  gastrohepatic  omentum,  the  hepatic 
artery  lying  alongside  and  to  the  left,  the  portal  vein  behind  and  between  the  two.  In  the  second 
part  of  its  course  it  lies  behind  the  first  portion  of  the  duodenum ;  in  the  third  it  is  placed  between 


Fig.  6/. 


Liver 
Gall  bladder 

Hepatic  duct 

Inferior  vena  cava 

Cystic   duct 

Right  suprarenal  vein 

Hepatic  artery 

Portal  vein 

Right  suprarenal  capsule 

Gastroduodenal  artery 
Right  renal  vein 
Superior  mesenteric  artery 
Common  bile  duct 

Right  kidney 

Descending  portion 
of  duodenum 
Head  of  pancreas    -■ 

Superior  mesenteric 
vein 

Colica  dextra  artery 


Ascending  portion  of 
duodtnum 

Right  ureter 


Descending  aorta 


Gastric  artery 
Coronary  vein  of  stomach 
Inferior  phrenic  arteries 
Celiac  axis 

Left  suprarenal  capsule 
Hepatic  artery 
Left  renal  artery 
Left  suprarenal  vein 
Splenic  artery 


Gastric  surface  of  spleen 
J  Splenic  veins 
Tail  of  pancreas 


Inferior  moenleric  vein 


Lelt  kidney 
Duodeno-jcjunal  flexure 

Inferior  mesenteric  artery 

Left  ureter 
Abdominal  aorta 


THE   CONTENTS   OF   THE   ABDOMEN. 


133 


the  second  portion  of  the  duodenum  and  the  head  of  the  pancreas,  opening  finally  into  the  second 
portion  of  the  duodenum  on  its  inner  and  posterior  aspect  a  little  behind  and  below  the  middle. 
(4)  The  relatively  large  size  of  the  liver  in  children  must  not  be  forgotten. — Ed.] 

The  Spleen. — The  spleen  is  deeply  placed  in  the  left  hypochondrium  and  its  relations  may 
be  made  clear  by  a  description  of  the  three  surfaces  of  the  organ.  The  largest  or  convex  surface, 
jacies  diaphragmatica,  borders  immediately  upon  the  inferior  surface  of  the  diaphragm  (Plates 
15  and  16  and  also  Fig.  62).  In  inflammations  of  the  peritoneal  covering  of  the  spleen  (peri- 
splenitis) the  practical  clinician  may  occasionally  hear  a  peritoneal  friction  fremitus,  in  this  situ- 
ation, produced  by  the  respiratory  movements  of  the  diaphragm.  It  should,  nevertheless,  be 
remembered  that  the  pleural  cavity  is  superimposed  upon  the  upper  portion  of  the  spleen  in  this 
situation  (Plate  15  and  Fig.  62),  so  that  a  peritoneal  friction  sound  must  not  be  confused  with 
a  friction  rub  proceeding  from  the  contiguous  pleural  surfaces  above  the  diaphragm.  The  inter- 
position of  the  inferior  margin  of  the  lung  between  the  spleen  and  the  costal  wall  explains  the  fact 
that  it  is  impossible  to  outline  the  upper  border  of  the  spleen  by  percussion  (Plate  13,  left).  After 
the  subsidence  of  an  inflammation  the  facies  diaphragmatica  of  the  spleen  is  frequently  adherent 
to  the  diaphragm.  The  facies  gastrica  (Fig.  61  and  Plate  15)  is  concave  and  is  in  relation  with 
the  fundus  of  the  stomach;  upon  this  surface  is  the  hilus  for  the  entrance  of  the  splenic  artery 
(from  the  celiac  axis)  and  for  the  exit  of  the  splenic  vein.  Since  this  vein  empties  into  the  portal 
vein,  we  can  easily  understand  the  occurrence  of  splenic  enlargement  consequent  upon  stasis 
within  the  liver  (in  cirrhosis  hepatis,  for  example).  The  smallest  surface  of  the  spleen  is  the 
long  and  narrow  jacies  renalis,  which  is  in  relation  with  the  convex  border  of  the  left  kidney 
(Plate  15  and  Fig.  61).  This  surface  may  be  felt  in  the  dead  body  by  following  the  facies  dia- 
phragmatica posteriorly. 

The  most  important  clinical  sign  of  most  diseases  of  the  spleen  is  an  enlargement  of  the  viscus, 
and  in  order  to  recognize  this,  the  topography  of  the  spleen  must  be  known.  The  spleen  extends 
from  the  ninth  to  the  twelfth  ribs  and  approaches  to  within  two  centimeters  of  the  tenth  dorsal 
vertebra.  Its  longitudinal  axis  passes  obliquely  from  above  and  behind,  downward  and  forward, 
so  that  the  superior  pole  is  also  posterior  and  the  inferior  one  is  also  anterior.  This  inferior  pole 
extends  anteriorly  to  a  varying  degree;  its  normal  position  is  at  about  the  anterior  extremity 
of  the  eleventh  rib  (Plate  16).  It  is  the  portion  of  the  spleen  which  is  sometimes  felt,  but  it  is 
not  palpable  under  normal  conditions.  If  this  pole  can  be  palpated  beneath  the  costal  margin, 
the  spleen  is  enlarged.  The  inferior  pole  of  the  spleen  borders  upon  the  splenic  flexure  of  the 
colon  (Plate  17) ;  if  this  portion  of  the  intestine  is  not  filled  with  feces,  so  that  it  gives  a  tympanitic 
note,  the  splenic  margin  in  the  longitudinal  axis  of  the  viscus  may  be  defined  by  percussion.  If 
a  tumor  of  the  spleen  is  present,  the  inflated  splenic  flexure  of  the  colon  may  be  interposed  between 
the  facies  diaphragmatica  of  the  spleen  and  the  diaphragm.  It  is,  of  course,  impossible  to  deter- 
mine the  boundary  between  the  spleen  and  the  kidney  by  percussion;  such  an  attempt  is  most 
likely  to  succeed  at  the  inferior  portion  of  the  viscus  near  its  posterior  margin  in  the  region  of  the 
"lieno-renal"  angle  (Plate  12).  It  will  be  observed  that  palpation  is  of  more  importance  than 
percussion  of  this  organ. 

Although  the  spleen  is  attached  to  the  diaphragm  by  the  ligamentum  phrenico-lienale  and 
to  the  stomach  by  the  ligamentum  gastrolienal,  and  is  also  supported  from  below  by  the  liga- 


134  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

Fig.  63. —  The  liver,  seen  from  below. 

Fig.  64. — The  position  of  the  structures  at  the  porta  hepatis. 

mentum  phrenico-colicum,  this  fixation  is  not  firm  enough  to  hinder  the  occurrence  of  "floating 
spleen,"  which  is  accompanied  by  a  stretching  of  these  ligaments.  Like  the  liver,  the  spleen 
may  be  displaced  by  tympanites,  by  ascites,  or  by  abdominal  tumors,  which  press  the  organ 
upward  toward  the  pleural  cavity,  or  by  a  left-sided  pleural  exudate  which  forces  the  spleen, 
together  with  the  diaphragm,  downward.  An  abscess  of  the  spleen  may  perforate  into  the 
left  pleural  cavity,  into  the  stomach,  into  the  intestine,  and  even  into  the  pelvis  of  the  left 
kidney. 

The  Pancreas. — The  pancreas  (Plates  15,  17,  and  18,  and  Figs.  61  and  68)  may  be  seen 
and  felt  through  the  gastrohepatic  omentum  in  the  posterior  wall  of  the  bursa  omentalis.  It  may 
be  exposed  in  three  ways:  (1)  By  dividing  the  gastrohepatic  omentum  and  displacing  the  stomach 
downward;  (2)  by  dividing  the  ligamentum  gastrocolicum  (see  page  113)  and  displacing  the 
stomach  upward;  and  (3)  by  dividing  the  floor  of  the  bursa  omentalis,  i.  e.,  the  transverse  meso- 
colon, and  reflecting  upward  the  transverse  colon  and  the  stomach.  The  long  flat  organ  is 
transversely  situated  at  the  level  of  the  second  lumbar  vertebra;  it  is  retroperitoneal,  only  the 
anterior  portion  of  the  viscus  being  covered  by  the  peritoneum  of  the  bursa  omentalis.  The 
"head"  lies  in  the  concavity  of  the  duodenum  (Fig.  61),  but  sufficient  space  is  left  for  the  superior 
mesenteric  vessels  to  pass  beneath  the  inferior  pancreatic  margin  and  over  the  ascending  portion 
of  the  duodenum  to  reach  the  root  of  the  mesentery.  The  tail  lies  upon  the  anterior  surface  of 
the  left  kidney,  sometimes  higher,  sometimes  lower,  and  extends  to  the  [basal  surface  of  the 
— Ed.]  spleen.  The  posterior  surface  is  separated  from  the  vertebral  column  by  the  crura  of 
the  diaphragm,  by  the  inferior  vena  cava,  and  by  the  abdominal  aorta  (Fig.  69).  There  is  a 
groove  upon  the  dorsal  surface  of  the  head,  which  lodges  the  superior  mesenteric  artery  and 
vein.     The  splenic  vessels  run  along  the  upper  border  of  the  organ. 

Owing  to  the  deep  position  of  the  pancreas  it  is  difficult  to  make  a  positive  diagnosis  of  its 
diseases,  such  as  cysts,  abscesses,  or  tumors.  The  extension  of  such  diseases  to  the  stomach  is 
preceded  by  adhesions  to  the  posterior  gastric  surface  within  the  bursa  omentalis.  In  spite  of 
all  this,  clinicians  have  succeeded  in  palpating  the  head  of  the  pancreas  through  the  abdominal 
walls  in  spare  individuals.  It  will  be  readily  understood  that  the  intimate  relations  with  the 
transverse  colon,  with  the  duodenum,  with  the  pylorus,  and  with  the  transverse  fissure  of  the  liver 
add  greatly  to  the  difficulty  of  making  a  positive  diagnosis  of  the  diseases  of  the  pancreas,  par- 
ticularly of  carcinoma  of  the  head  of  the  viscus. 

The  Duodenum. — The  duodenum  (duxhxdSdzTuXov,  because  twelve  inches  long)  extends 
from  the  pylorus  to  the  duodenojejunal  flexure  and  has  a  length  of  about  thirty  centimeters.  The 
commencement  of  the  pylorus  is  often  made  visible  by  a  constriction,  but  it  may  be  more  surely 
determined  by  palpation  of  the  thickening  produced  by  the  muscular  tissue,  which  is 
plentiful  in  this  situation  (sphincter  pylori).  The  pars  superior,  the  shortest  portion, 
lies  to  the  right  of  the  median  line  at  the  level  of  the  first  lumbar  vertebra  and  is 
attached  to  the  transverse  fissure  of  the  liver  by  the  ligamentum  hepatoduodenale  [right 
edge    of   the    gastrohepatic  omentum. — Ed.].     This   ligament   forms  the  anterior  boundary 


Inferior  vena  cava 


Iinpressio  oesophagea 

Spigelian  lobe 


Tuber  omentale 

Portal  vein 

Hepatic  artery 

Left  lobe 

Impr.  pylorica 

Lig.  teres 
Quadrate  lobe 

Fossa  venae 
umbilicalis 


Right  hepatic  vein 
Left  hepatic  vein  p 


Fig.  6j. 


Spigelian  lobe 
Hepatic  artery 

Left  lobe  _ 

Hepatic  duct  __ 
Cystic  duct  _. 

Quadrate  lobe 


Ligamentum  teres 
(umbilical  vein) 


Fossa  venae 
umbilicalis 


Impressio 
suprarenalis 

Impr.  renalis 

Impr.  duoden. 
Common  bile  duct 
Cystic  duct 


Impr.  colica 
Gall  bladder 


Fig.  64. 


Inferior  vena  cava 


Common  bile  duct 
Portal  vein 


Hepatic  lymphatic 
glands 


Right  lobe 


Gall  bladder 


THE   CONTENTS   OF  THE   ABDOMEN.  1 35 

of  the  entrance  into  the  bursa  omentalis.  The  peritoneum  passes  from  the  ligament  to 
the  anterior  surface  of  the  pars  superior;  the  posterior  surface  of  this  portion,  directed 
toward  the  bursa  omentalis,  is  also  covered  by  peritoneum.  The  remaining  portions 
of  the  duodenum,  on  the  contrary,  are  covered  only  anteriorly  by  a  peritoneal  reflection, 
but  even  this  is  completely  wanting  in  two  narrow  places,  namely,  at  the  crossing  of 
the  transverse  mesocolon  and  at  the  crossing  of  the  superior  mesenteric  vessels  (Plate  15). 
When  the  stomach  is  empty,  the  superior  portion  of  the  duodenum  runs  in  a  frontal  direction, 
but  when  the  stomach  is  full,  it  lies  more  in  a  sagittal  plane.  It  is  situated  just  beneath  the 
quadrate  lobe  of  the  liver.  The  pars  descendens  (Plates  15  and  18  and  Figs.  61  and  67  )  lies  at  the 
right  side  of  the  second  lumbar  vertebra  and  is  crossed  at  right  angles  by  the  transverse  colon. 
If  one  desires  to  see  the  interior  portion  of  the  pars  descendens,  which  disappears  at  the  upper 
margin  of  the  transverse  colon,  the  transverse  colon,  together  with  the  great  omentum,  must 
be  reflected  upward.  This  renders  visible  the  duodenum,  upon  the  posterior  abdominal  wall, 
and  the  region  of  the  flexura  inferior  duodeni,  i.  e.,  the  transition  of  the  descending  into  the 
ascending  portion.  The  pars  descendens  produces  the  impressio  duodenalis  upon  the  right 
lobe  of  the  liver  (see  page  131);  the  external  convex  margin  of  this  portion  of  the 
intestine  borders  upon  the  internal  margin  of  the  right  kidney1  (Plate  15  and  Figs.  61  and 
67),  to  which  the  peritoneal  covering  of  the  duodenum  is  reflected;  the  interior  border  is 
in  relation  with  the  inferior  vena  cava.  The  pars  ascendens  passes  to  the  left,  and  after  crossing 
the  inferior  vena  cava,  at  the  level  of  the  third  lumbar  vertebra,  and  the  abdominal  aorta  (Fig. 
61  and  Plate  18)  becomes  continuous  with  the  duodenojejunal  flexure  at  the  left  of  the  vertebral 
column.  The  root  of  the  mesentery,  running  in  an  approximately  vertical  direction,  crosses  the 
duodenojejunal  flexure  (Plate  15)  and  contains  the  superior  mesenteric  artery  and  vein,  the 
vein  being  situated  to  the  right  of  the  artery  (see  also  Plate  61). 

The  upper  portion  of  the  duodenum  is  the  seat  of  predilection  for  duodenal  ulcers.  Since 
this  part  is  covered  anteriorly  and  posteriorly  by  peritoneum,  ulcers  situated  in  the  posterior, 
as  well  as  those  located  in  the  anterior  wall  of  the  duodenum  may  perforate  into  the  peritoneal 
cavity.  (Perforating  ulcers  of  the  posterior  duodenal  wall  open  into  the  bursa  omentalis.) 
Such  a  perforation  into  the  peritoneal  cavity  may  be  prevented  by  preceding  adhesions  between 
the  duodenum  and  the  liver,  the  gall-bladder,  or  the  posterior  abdominal  wall. 

The  Small  Intestine.— The  small  intestine  is  from  six  to  eight  meters  (twenty  to  twenty- 
five  feet)  long  (jejunum  about  three-fifths,  ileum  about  two-fifths  of  the  total  length)  [ac- 
cording to  English  and  American  authors,  this  is  reversed,  the  jejunum  comprising  two-fifths, 
the  ileum  three-fifths.— Ed.],  and  its  numerous  coils  fill  the  space  below  the  transverse  colon 
and  the  transverse  mesocolon,  overlie  more  or  less  the  ascending  and  descending  colon,  and 
rest  upon  the  iliac  fossas,  as  well  as  upon  and  between  the  pelvic  viscera  (Plates  1 1  and  16).  The 
great  omentum  (Plate  16;  it  has  been  removed  in  Plate  n)  hangs  down  from  the  transverse 
colon,  and,  according  to  the  degree  of  its  development,  separates  the  intestines  more  or  less  com- 
pletely from  the  anterior  abdominal  wall.  There  is  a  certain  regularity  in  the  course  pursued 
by  the  intestinal  coils,  but  it  is  subject  to  great  variation. 

The  superior  mesenteric  artery,  the  second  of  the  single  visceral  branches  of  the  abdominal 
aorta,  enters  the  root  of  the  mesentery  at  the  lower  margin  of  the  pancreas  (Plate  15  and  Fig. 


136  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

PLATE  17. 
The  position  of  the  pylorus,  cardia,  large  intestine,  and  spleen  of  a  fifteen-year-old  girl.     A  deeper  layer  of  the 
model  of  Plate  16. 

61).     This  vessel  supplies  all  of  the  small  intestine  and  a  considerable  portion  of  the  large  in- 
testine.    Its  branches  are: 

1.  The  inferior  pancreaticoduodenalis,  to  the  duodenum  and  the  head  of  the  pancreas; 

2.  The  vasa  intestini  tenuis  (arteria  intestinales),  about  fifteen  in  number,  running  in  the 
mesentery  to  the  intestinal  coils; 

3.  The  ileocolic  artery  to  the  terminal  portion  of  the  ileum  and  to  the  commencement  of 
the  ascending  colon; 

4.  The  arteria  colica  dextra  to  the  ascending  colon; 

5.  The  arteria  colica  media  to  the  transverse  colon. 

This  vessel  consequently  supplies  that  portion  of  the  intestinal  tract  extending  from 
the  duodenum  to  the  splenic  flexure  of  the  colon.  The  intestine  beyond  this  point  is 
supplied  by  the  third  single  visceral  artery,  the  injerior  mesenteric  (Plate  15),  which  arises 
from  the  abdominal  aorta  at  the  level  of  the  third  lumbar  vertebra.  It  runs  behind  the  peri- 
toneum and  divides  into  two  main  branches: 

1.  The  arteria  colica  sinistra  to  the  descending  colon,  and 

2.  The  superior  hemorrhoidal  artery  to  the  rectum.  The  sigmoid  arteries  supply  the 
sigmoid  colon. 

The  portal  vein  is  a  very  large  venous  trunk,  only  three  centimeters  in  length,  which  enters 
the  liver  at  the  transverse  fissure.  It  receives  the  blood  from  that  portion  of  the  gastro- 
intestinal tract  which  is  situated  between  the  cardia  and  the  anus,  from  the  pancreas,  from 
the  spleen,  and  from  the  gall-bladder,  and  transmits  it  to  the  liver,  from  which  it  reaches  the 
inferior  vena  cava  through  the  hepatic  veins.  It  will  be  noted  that  the  blood  from  the  three 
single  visceral  branches  of  the  abdominal  aorta  passes  into  the  inferior  vena  cava  by  an  indirect 
route  through  the  liver,  while  the  blood  from  the  paired  branches  (visceral  and  parietal)  emp- 
ties directly  into  the  inferior  vena  cava.  The  trunk  of  the  portal  vein  lies  in  the  hepato- 
duodenal ligament  (see  pages  125-127)  and  arises  behind  the  head  of  the  pancreas  by  the 
union  of  the  splenic,  the  superior  mesenteric,  and  the  inferior  mesenteric  veins  (Figs.  61  and 
69).  The  important  anastomoses  of  the  portal  system  have  been  described  upon  page  122. 
In  the  region  of  the  portal  vein  there  are  more  blood-vessels  compressed  into  a  comparatively 
small  space  than  in  any  other  portion  of  the  body  (Fig.  61). 

The  Large  Intestine. — The  large  intestine  commences  with  the  cecum  and  with  the  ver- 
miform appendix  (Plates  14  and  18),  one  of  the  most  fertile  regions  of  modern  surgery.  The 
cecum  lies  in  the  right  iliac  fossa  upon  the  iliac  fascia  and  the  iliacus  muscle;  it  extends  to 
the  left  as  far  as  the  outer  margin  of  the  right  psoas  major  muscle.  Like  the  vermiform  process, 
it  usually  possesses  a  complete  peritoneal  reflection,  and  is  consequently  in  contact  with  the 
inner  surface  of  the  abdominal  wall.  In  contrast  to  the  ascending  colon,  it  is  a  comparatively 
movable  portion  of  the  intestine.  The  posterior  peritoneal  covering  may  be  wanting,  however, 
and  the  cecum  is  then  adherent  to  the  iliac  fossa.  The  vermiform  process  is  usually  freely 
movable,  being  fixed  only  by  its  own  mesenteriolum  and  partly  covered  by  the  cecum.  .  It  may 


17 


Gl.   thyreoidea 
Thyriiid  gland 

Trachea 

Trachea 

V.  anon vi 

Left  innominate  \>in 

Aorta  a5"''r' 'U1,1 
A.  puftfWflH*  ;">rta- 

Right  pulm.^o  ,rwn 

Right  pulmonary  veins 

Pericardium 
,,  Pericardium 
v .  cava  inf. 

Diaphragm 
L°bULeftiiibeh«el. 

M  ncmMsatto 


E»phagtis     ° 


FleXU,;  Duodenojejunal  flexure 


Root  of  mesentery 


kginoJd  ftextire  trf  colon 
Vesica  uftjjuja 

Symphysis 


Esophagus 
rib 

>pleen 


Diaphragmatic  surface  of 
I  ail  (if  pancreas 
Splenic  flexure  of  colon 


1  >cscending  colon 
Quadratus  lumborum 


Left  ureter 
Kectum 
Sacrum 
Vagina 

Sphincter  ani  externus 


1 

•ancrcaftf""  /  N 

intestini  tenu  / — — 

•  the  int»«Hlrt*tWfeJ*I~— 

;h#&*yiJ*frn<M»#-->rTf 1"  m   ~~~ 

•lica  dextra  to 

auitonoid  iKl 

I  to  th 
ssel   conse^fW 

num   to   th>'   splootitfqo&a 1— ~ .      .   . 

>y  the  third  single^vj^al  ahcrv,   th<  '  "71 

ibdomin;;  NJt"  the  thir  . — i — e uL-w^^*^ 

um  and  dividef^ftftTxvo 3n^irT 

i .  The  arteria  coli'  a  sinistra  to  the\ 


. tn 

Btio£  gnil 

soomlvq  iriyiM 

i.iln/.  ht/1 

:.noinljxi  iriglH 


einimubdjs  au*»H 


2.  The  superjofcj^g^arj^j^l  arte 


(1  colon. 


moid  arteries  supply  the 


;m  is  th. 
.     xed  only 


length,  which  enters 


\ 

t|2 , 1 • 

ion   of  tli' 

~~  ^F»ft1WpH^uftie 
d   from  the  three 

— i — )—  -,;i 


Tjttnidqii 


lUKjfi.1 


Tab.  17. 


Gl.  thyreoidea 
Trachea 

V.  anonyma  sin._ 

Pericardium  — 
Aorta  ascendens. 
A.  pulmonalis  dex.. 
Cavum  pericardii. 
Vv.  pulmonales  dex.^„. 

Pericardium  ■ 

V.  cava  inf. 

Diaphragma 

Lobus  sin.  hepatis 
M.  rectus  abdominis 


Oesophagus 

^ A.  subclavia 

M»^B -A-  carotis  sin. 

— A.  anonyma 

A.  pulmonalis  sin. 
Bronchus  sinister 
Aorta  descendens 
Oesophagus 
Costa  X 

Facies  gastrica  lienis 
Cardia 

Facies  diaphragmatica  lienis 
Cauda  pancreatis 
Flexura  coli  sinistra 

M.  psoas 

Colon  descendens 

M.  quadratus  lumborum 

Crista  iliaca 

Ureter  sinister 
Rectum 
Os  sacrum 
Vagina 

M.  sphincter  ani  externus 


THE  CONTENTS    OF  THE  ABDOMEN.  I37 

be  entirely  concealed  behind  the  cecum,  however,  and  also  adherent  to  the  posterior  abdominal 
wall.  If  a  foreign  body  is  lodged  in  the  vermiform  appendix,  a  resulting  inflammatory  process 
may  terminate  in  perforation.  Since  the  appendix  is  completely  surrounded  by  peritoneum 
the  intestinal  contents  may  flow  into  the  peritoneal  cavity,  provided  that  the  vermiform  process" 
has  not  been  bound  down  to  the  iliac  fossa  and  to  the  neighboring  organs  by  preceding  inflam- 
matory adhesions. 

[The  length  and  direction  of  the  appendix  are  subject  to  great  variation.  According  to 
Wolsey,  the  directions  assumed,  in  the  order  of  frequency,  are  as  follows:  (i)  Retrocecal, 
i.  e.,  upward;  (2)  pelvic;  (3)  upward  and  inward;  (4)  variable.  Allowing  for  variations,  how- 
ever, the  appendix  will,  in  the  majority  of  cases,  be  found  in  the  right  lumbar  region,  some 
part  of  it  extending  frequently  into  the  adjoining  regions. 

The  relations  of  the  appendix  to  the  anterior  abdominal  walls  are  interesting  and  important. 
McBurney's  point  on  the  omphalo-spinous  line  (2£  to  3  inches  from  the  anterior  spine  and 
at  or  near  the  outer  border  of  the  rectus)  does  not,  anatomically,  exactly  represent  the  base 
of  the  appendix,  the  latter  lying  somewhere  in  a  circle  two  inches  in  diameter  with  the  "point  " 
as  its  center;  it  does  indicate,  however,  with  sufficient  accuracy  the  seat  of  the  localized  tender- 
ness in  cases  of  appendicitis. — Ed.] 

The  ascending  colon  (Plates  11  to  15)  runs  from  the  upper  portion  of  the  right  iliac  to  the 
inferior  pole  of  the  right  kidney.  Below  or  upon  this  point  it  is  continued  into  the  transverse 
colon  by  the  hepatic  flexure,  which  produces  the  impressio  colica  (see  page  131)  upon  the  super- 
imposed right  lobe  of  the  liver.  The  ascending  colon  lies  upon  the  quadratus  lumborum 
muscle,  to  the  outer  side  of  the  psoas,  and  is  covered  by  peritoneum  only  upon  its  anterior  and 
lateral  surfaces;  its  posterior  surface  is  therefore  more  or  less  fixed  to  the  posterior  abdominal 
wall  by  connective  tissue.  It  consequently  does  not  seem  to  be  freely  movable  and,  particularly 
in  the  contracted  state,  is  concealed  anteriorly  by  the  overlying  intestinal  coils.  Perityphlitic 
abscesses  are  situated  in  the  retroperitoneal  connective  tissue  which  fixes  the  origin  of  the 
ascending  colon,  and  occasionally  also  the  cecum,  to  the  iliac  fascia.  From  this  situation  the 
suppuration  may  extend  in  three  directions: 

1.  Upward  beneath  the  kidneys  as  far  as  the  diaphragm; 

2.  Downward  and  inward  over  the  iliopectineal  line  into  the  true  pelvis; 

3.  Downward  and  forward  beneath  Poupart's  ligament  to  the  subinguinal  region  of  the 
thigh. 

The  transverse  colon  (Plates  11,  14,  and  17)  commences  at  the  hepatic  flexure  and  runs 
toward  the  left  in  a  slightly  ascending  direction  until  it  reaches  the  left  hypochondrium,  where 
it  is  continued  into  the  descending  colon  by  the  splenic  flexure.  Although  the  splenic  flexure 
is  somewhat  higher  than  the  hepatic  flexure,  we  may  say  that  the  direction  of  the  transverse 
colon  generally  corresponds  to  the  transverse  line  connecting  the  lowest  points  of  the  costal  mar- 
gins (Plate  11).  The  transverse  colon  is  concave  above  and  convex  below  in  conformity  with 
the  overlying  greater  curvature  of  the  stomach.  Upon  the  right  the  colon  is  covered  by  the  liver 
and  the  gall-bladder,  upon  the  left  it  is  in  contact  with  the  inferior  pole  of  the  spleen,  and  the 
first  part  of  the  descending  colon  rests  upon  the  lower  portion  of  the  anterior  surface  of  the  left 
kidney.     The  inferior  margin  of  the  transverse  colon  borders  upon  the  coils  of  the  small  intestine. 


138  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

PLATE  18. 
The  position  of  the  liver  (a  portion),  duodenum,  pancreas,  left  kidney,  and  cecum  of  a  fifteen-year-old  girl.     A 
deeper  layer  of  the  model  of  Plate  16. 

The  relation  to  the  duodenum  has  been  described  upon  page  134.  The  long  and  broad 
transverse  mesocolon  should  also  be  borne  in  mind,  since  it  is  responsible  for  the  fact  that 
the  transverse  colon  is  much  more  movable  than  the  ascending  or  descending  ones.  The 
transverse  colon  is  consequently  in  contact  with  the  anterior  abdominal  wall,  and,  if  its 
mesocolon  is  long  enough,  may  form  a  loop  the  convexity  of  which  is  directed  downward.  [At 
either  end  the  mesentery  of  the  transverse  colon  becomes  shorter,  approaching  the  arrangement  of 
the  ascending  and  descending  colons,  which  are  usually  without  any  mesentery. — Ed.] 

The  descending  colon  (Plates  n-17)  is  longer  than  the  ascending  colon  and  commences  at 
the  left  kidney.  It  runs  downward  upon  the  quadratus  lumborum  muscle,  somewhat  further 
from  the  median  line  than  the  ascending  colon,  reaches  the  left  iliac  fossa,  and,  after  a  short 
course  toward  the  middle  line,  becomes  continuous  with  the  sigmoid  colon  (omega  loop)  at  the 
external  iliac  vessels.  The  attachment  to  the  posterior  abdominal  wall  is  similar  to  that  of  the 
ascending  colon.  Since  the  broad  posterior  surfaces  of  the  ascending  and  descending  portions 
of  the  large  intestine  are  attached  to  the  posterior  abdominal  wall  by  connective  tissue,  it  is  pos- 
sible to  open  these  portions  of  the  intestine  from  behind  without  entering  the  abdominal  cavity. 
This  is  done  in  the  operation  of  lumbar  colotomy  when  an  artificial  anus  is  made  in  the  descend- 
ing colon  to  the  outer  side  of  the  quadratus  lumborum  muscle  above  the  left  iliac  crest.  (Find 
this  location  in  Plate  16.)  It  should  be  noted,  however,  that  these  portions  of  the  intestine  may 
occasionally  have  a  short  mesocolon,  the  peritoneal  reflection  being  almost  complete,  in  which 
case  the  operation  is  very  difficult  to  perform  without  opening  the  peritoneal  cavity.  The  sig- 
moid colon  is  the  most  favorable,  and  the  one  generally  preferred  for  the  performance  of  this 
operation,  in  a  case  of  rectal  carcinoma,  for  example,  where  the  intestine  is  occluded  above  the 
anus  (Plates  11  and  14-18).  It  is  situated  in  the  right  iliac  region  connecting  the  descending 
colon  with  the  rectum,  and  is  distinguished  from  the  former  by  its  long  mesocolon.  It  is  usually 
in  contact  with  the  anterior  abdominal  wall  upon  the  left  side  above  Poupart's  ligament,  and 
can  be  exposed  and  opened  in  this  situation.  This  operation  is  necessarily  preceded  by  a  lapar- 
otomy. In  making  an  artificial  anus  the  opening  made  in  the  intestine  must  be  united  with  the 
edges  of  the  abdominal  incision  so  that  none  of  the  intestinal  contents  may  find  their  way  into 
the  peritoneal  cavity.  In  this  operation  the  small  intestine  must  not  be  mistaken  for  the 
colon.  The  characteristics  of  the  colon  are  that  its  longitudinal  muscular  coat  is  arranged 
into  three  bands  or  taenia  and  that  it  has  epiploic  appendages  containing  fat.  This  region 
is  depicted  in  Fig.  57.  [Other  distinguishing  features  of  the  large  intestine  are:  its  sacculation, 
more  fixed  position, — in  the  case  of  the  more  movable  divisions,  their  continuity  with  the 
parts  relatively  fixed, — and,  as  a  rule,  larger  calibre.  In  addition,  the  large  intestine  is  more 
liable  to  contain  hardened  feces.  It  must  not  be  forgotten  that  the  longitudinal  bands  (taenia 
coli)  above  referred  to  spread  out  on  the  lower  part  of  the  sigmoid  so  as  to  make  a  covering  com- 
plete except  for  a  narrow  strip  along  either  side;  that  is,  the  three  narrow  bands  have  been 
reduced  to  two  wider  ones,  an  anterior  and  a  posterior.  In  the  rectum  these  bands  practically 
disappear. — Ed.]     In  cutting  from  without  inward  the  following  structures  are  divided:  skin, 


Tab 


J.s 


Gl.  llijmrtAttfaal 


Facies  mediastinalis  pt^M>ttti. 


InfVi.oc.anp*  <in*. 


He^Sff" 


- 


Pars  deSteWHtf" 

[<  num 
Pars  a8c<     duodenum 


External  ili.-. 

Righ 
fallopian  tube 


I,. 
Symphysis  - 
Clitoris 

Hail 

Labium  majus 


?W>r*fmiiiinister 

horacica) 

UUiApferagma 

CQrifedia 

fflQMHlAf1  lllprarenalis 

Tlftil<|npinM  i  mil 

«-ferii4*rrister 

%?'lq«»«lK«*tMrukimborum 
AAd^*a0««?ftWJr5ploitebdon,inalU> 

I4JHP>  ilium 

$#*)*»  H«*g*i«JtAflMPl 

Siisunjacrum 
H*w**J><«v«»giriaHs 
.VDnVl»illhriTeoti 
V^tMjina 

W:.r^JhP!hW»1r  *Hi    ext. 
fcrWhra 


i3« 


TOPOGRAPHIC    . 


The  position  of  the  liver  (a  portion"),  du 
deeper  layer  of^the  model  of  Plate  16. 


The  relation  to  the  duodenum 

transverse  mesocolon  should 

the  transverse  colonua#ww» -— — ►— 


transverse   colon   is  tfyrYSequentl 


y 

borne   in  mind,  since  it  is  re .-;■  that 

giovable.  than   the  ascending  01 
m   Contact  "with  the  antenbr  abdominal  if   its 

mesocolon  is  long  enough,  may  form  a  loop  the  convexity  of  wAich  is  dir  [At 

either  end  the  mesentery  of  the  transverse  colon  becomes  shorter,  avpi 
the  ascending  anoMk^(^ing  cokina,  which  qpe*  Usually  Without  \nv 

The  descending  colon  (Plates\  11-17)  is  longerThaii  tin  drrrnrliiy  nmli  n  [miti 
the  left  kidney.     It  runs  downward  upon  the  quadratus  lumboruny  mfty(4pv 

~  leending  colon,  reaches  .the  left  iliac  ftt*sayo*iftii+ini 


from  the  mediatf^Ml^^Eafr'tfTe4' 

course  toward  the  middle  line,  be| 

external  iliac  vessels.m8E'fRie1- 

ascending  colon.     Since  the  broad\  posterior  surfaces  of  the  ascend i 

of  the  large  intestine  are  attached  tb  the  posterior  abdominal  wall  by  connective  tissue,  it  is 

sible  to  open  the^pbftWfrtt?  of  the  intcotino  from  behind  with( 


omes  continuous  with  the  sigmoitl  colon  (omeg; 

posterior  abdominal  wall  is  similar  to  tba 
■g-»ri4  descendin  ' 


This  is  done  in  the  operation  of  lui 


Jkfctadusbdominal  cavity. 
)0.r  coiotomy  when  a*n  artificial  a  Tus°is  made  in  the  descend- 


ing colon  to  the  wrtefi taWnf  Mip  ijiti.ilrm.iK  liimbomm  mimrlp  ahovfj  1 1t-g^fa  iliac  crest.  (Find 
this  location  in  Plate  16.)  It  shoulc  be  noted,  however,  that  thene  p4rtBf>tes*g>fr'#i|H»ftffi>tine  may 
occasionally  have  a^sn'on  mesocolon,  the  peritoneal  reflection  being  bln^ftfrnffii^ptefefriin  which 
case  the  operation  is  very  difficult  t  >  tperform  without  opening  the  pfri^on#f&"cJjHteA  The  sig- 
moid colon  is"?ne  mosliavorable,  and  "the  one  generally  preferred  fcjr  the  ^e^flffmance  of  this 
operation,  in  a*^sF'oTTecfaFcarci»oma,  for  example,  where  the  intestine  is  occluded  above  the 
anus  (Plates  11  ana  14^10)"  It /s  situated  in  the  right  ihac  region /connecting  the  descending 
colon  with  the  rectum,  and  is  distinguished  from  the  forniefJ^iiJliUong_tiift6«tolon.  It  is  usually 
in  contact  with  the  anterior  avdominrei  wall  upon  the  left  side  abc/ve  Poupart's  ligament,  and 
can  be  exposed  and  opened  in/this  situation.  This  operation  is  ne/essarily  preceded  by  a  lapar- 
iv.     In  making,  an.  artificial  anus  the  opening  made  in  the  m/estme  must  oe  united  with  the 

-4 ■ •  °  JL two  JriiiH 

mmal  incision  so  that  none  of  the  intestinal  Contents  ma,vn[|[Qd,.-.1thci;- 
the  p  '""Tyf  jniTr-operation   the.  t.mall  intcr.tirre   must   nat^'be  mistaken  for  the 

■    :  /        «    that  its  longitudinal   mustHttlar  coat 
A hfis  epiploic   appendages    'ontn^JQ^ J-.rf.     Tj 


the  large  intestine  are:    it-  tion, 

-eijoliD 


into  thn  o 

is  depicted  iff 

more  fixed  position, — in  ;  \  lovable  divisions,  their  continuity  with  the 
parts  relatively  fixed, — an<,  \^^  rrbrr — lir  ttdd}tioii,  tlie^rffi^ffrlestine  is  more 
liable  to  contain  hardened  feci  rl  rgotten  that  the  longitudinal  bands  (taenia 
coli)  above  referred  to  spread  out  oi  ring  com- 
plete except  for  a  narrow  strip  along  'bat  is,  the  I  bands  have  been 
reduced  to  two  wider  ones,  an  anterio?  •  bands  practically 
disappear. — Ed.]     In  cutting  from  wit!  divided:  skin, 


Tab.  18. 


Gl.  thyreoidea 


V.  cava  sup. 
A.  pulmonalis  dex. 

Facies  mediastinalis  pulmonis  dcxtri 
W.  pulmonales  dextrae 

Lig.  pulmonale 
V.  cava  inf. 


Hepar 

Vesica  fellea 
Pylorus 

Pancreaa 
Flexura  coli  dextra 

Pars  descendens  duodeni 


Pars  ascendens  duodeni   -  I 


Coecum 


A.  iliaca   ext. --- 
Ovarium   dextrum— 

Tuba  ^^B 

Vesica  urinaria  *~""*  ■i&S?^' 

Symphysis — " 

Clitoris 

Labium  majus 


OS  sacrum 
Portio  vaginalis 
Ampulla  recti 

Vagina 
_.M.  sphincter  ani  ext. 

Urethra 


THE  CONTENTS   OF  THE  ABDOMEN.  139 

superficial  fascia,  the  three  flat  abdominal  muscles,  the  transversalis  fascia,  and  the  peri- 
toneum. The  inferior  epigastric  vessels  should  be  avoided  by  the  rule  given  upon  page  121. 
The  following  peritoneal  pockets  or  recesses,  the  development  of  which  is  subject  to  extraordi- 
nary variations,  may  occasionally  become  enlarged,  contain  portions  of  the  intestine,  and,  in 
this  manner,  lead  to  the  formation  of  the  so-called  retroperitoneal  hernias. 

1.  Recessus  duodenojejunal,  to  the  left  of  the  duodenojejunal  flexure.  It  is  open  an- 
teriorly and  is  bounded  upon  the  right  by  the  ascending  portion  of  the  duodenum  and  upon 
the  left  by  the  plica  duodenojejunal  of  the  peritoneum,  which  contains  the  inferior  mesenteric 
vein  [which  vein,  therefore,  would  lie  in  the  anterior  part  of  the  neck  of  a  hernia  occurring  here. 
— Ed.].  As  a  rule,  it  is  large  enough  to  receive  the  tip  of  the  finger.  It  is  found  by  reflecting  the 
transverse  colon  and  great  omentum  upward  and  displacing  the  small  intestine  with  its  mesen- 
tery to  the  right. 

2.  Recessus  ileocaecalis  superior,  just  above  the  ileocecal  junction.  The  opening  of  this 
recess  is  directed  toward  the  left  and  is  bounded  anteriorly  by  a  peritoneal  fold  passing  from  the 
mesentery  of  the  terminal  portion  of  the  ileum,  downward  and  toward  the  right  to  the  cecum. 

3.  Recessus  ileocaecalis  inferior,  just  beneath  the  end  of  the  ileum.  It  is  open  toward  the 
left  and  is  situated  between  the  mesenteriolum  of  the  appendix  and  a  peritoneal  fold,  the  plica 
ileocaecalis,  passing  from  the  end  of  the  ileum  to  the  cecum. 

4.  Recessus  intersigmoideus,  beneath  the  line  of  attachment  of  the  sigmoid  mesocolon. 
The  Kidneys. — Each  kidney  has  a  superior  and  an  inferior  pole,  an  external  convex  and 

an  internal  concave  margin,  and  an  anterior  and  a  posterior  surface.  They  are  situated  in  the 
lumbar  region  to  either  side  of  the  vertebral  column  upon  the  psoas  major,  quadratus  lumborum, 
and  transversalis  muscles,  and  upon  the  crura  of  the  diaphragm  in  such  a  manner  that  the  longi- 
tudinal axes  of  the  kidneys,  i.  e.,  the  lines  connecting  the  two  poles,  are  not  parallel  to  the  verte- 
bral column  but  diverge  slightly  as  they  pass  downward.  The  transverse  axis,  i.  e.,  the  line 
connecting  the  middle  points  of  the  two  margins,  is  not  situated  in  a  frontal  plane,  but  the 
continuations  of  the  two  axes  intersect  at  about  a  right  angle  in  front  of  the  vertebral  column, 
so  that  the  anterior  surface  is  also  external  and  the  posterior  one  is  also  internal.  The  convex 
border  is  the  most  posterior;  this  is  favorable  for  the  surgeon  who  sometimes  attacks  the  kidney 
from  behind,  in  order  to  open  it,  and,  after  operative  procedures  in  its  interior,  sutures 
it  together  again.  The  kidneys  extend  from  the  lower  border  of  the  eleventh  dorsal  vertebra 
to  the  third  lumbar  vertebra;  in  two-thirds  of  the  cases  the  right  kidney  is  placed  a  fingerbreadth 
lower  (Plates  12  and  15).  The  superior  pole  is  consequently  situated  in  the  last  intercostal 
space;  penetrating  wounds  in  this  situation  may  therefore  involve  the  pleural  cavity  (sinus  phren- 
icocostalis)  and  the  kidney,  particularly  the  left  kidney,  which  is  placed  somewhat  higher. 
For  this  reason  it  is  also  dangerous  to  resect  the  last  rib  in  operations  upon  the  kidney.  Ab- 
scesses of  the  kidney  may  point  upward  and  backward,  perforate  the  diaphragm,  and  rupture 
into  the  pleural  cavity,  or  even  into  the  lung;  in  such  a  case  pus  from  the  kidney  may  be  expec- 
torated. Only  the  anterior  surface  of  the  kidney  is  covered  by  peritoneum.  The  posterior 
surface  is  fixed  to  the  underlying  muscles  by  a  connective  tissue  rich  in  fat,  the  so-called  cap- 
sula  adiposa.  The  twelfth  thoracic  nerve  (n.  subcostalis)  and  the  iliohypogastric  nerve  (from 
the  lumbar  plexus)  run  in  this  fat  over  the  posterior  renal  surface  (Fig.  66).     These  nerves  are 


140  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

FlG.  65. — The   left   kidney   seen   from   in   front. 

Fig.  66. — The  right  kidney  seen  from  in  front. 

Fig.  67. — Anterior  view  of  the  relations  of  the  right  kidney. 

Fig.  68. — Anterior  view  of  the  relations  of  the  left  kidney. 

responsible  for  the  neuralgic  pains  which  accompany  renal  swellings  and  tumors  and  which 
may  radiate  into  the  thigh  and  into  the  external  genitalia. 

The  right  kidney  is  easily  found  by  elevating  the  liver,  the  right  lobe  of  which  bears  upon 
its  inferior  surface  the  impressio  renalis  (see  page  131  and  Fig.  63).  To  the  inner  side  of 
the  right  kidney  (Fig.  67)  are  the  inferior  vena  cava,  which  may  be  compressed  by  renal 
tumors,  and  the  descending  portion  of  the  duodenum.  Renal  abscesses  may  rupture  into  these 
structures  and  into  the  hepatic  flexure  of  the  colon  which  is  in  relation  with  the  inferior  pole  of  the 
kidney.  A  tumor  of  the  right  kidney  may  push  this  hepatic  flexure  forward  so  that  the  tumor 
will  apparently  give  a  tympanitic  note,  which  will  disappear  when  the  intestine  has  been  thor- 
oughly emptied.     The  colon  holds  a  similar  relation  to  the  left  kidney. 

The  left  kidney  is  more  concealed  than  the  right  one  and  is  not  so  easily  located  by  the  tyro. 
If  the  hand  is  pushed  around  the  spleen  until  it  reaches  the  facies  renalis  (see  page  133),  the  left 
kidney  may  be  palpated,  and  if  the  spleen  is  displaced  upward  the  inferior  pole  of  the  kidney 
may  be  made  to  appear  more  distinctly  in  the  angle  of  the  splenic  flexure  of  the  colon  (Fig.  68). 
The  remaining  portion  of  the  kidney  is  in  relation  anteriorly  with  the  tail  of  the  pancreas  and 
with  the  posterior  surface  of  the  stomach  (in  the  region  of  the  lesser  peritoneal  cavity).  Below 
the  pancreas,  the  kidney  is  covered  by  the  splenic  flexure  and  by  the  commencement  of  the 
descending  colon  (Fig.  68).  The  spleen  rests  upon  the  external  renal  margin  (Plates  12  and 
15  and  Fig.  61). 

More  distant  organs  may  also  be  involved  by  large  renal  tumors.  If  the  right  kidney  be- 
comes greatly  enlarged,  it  may  push  the  liver  upward  and  anteriorly  and  interfere  with  the  ex- 
pansion of  the  right  lung.  A  large  left-sided  renal  tumor,  in  addition  to  its  effect  upon  the 
stomach  and  the  spleen,  may  directly  compress  the  left  lung  and  the  heart.  Owing  to  the  firm 
foundation  of  the  kidney,  which  is  composed  of  strong  muscles  and  bones,  it  follows  that  en- 
largements in  the  posterior  direction  are  not  so  frequently  observed  as  those  extending  forward, 
upward,  and  downward.  Diseases  of  neighboring  structures,  such  as  hepatic  abscesses,  psoas 
abscesses,  and  caries  of  the  vertebras,  may  extend  to  the  kidney. 

The  surgeon  naturally  prefers  to  attack  the  kidney  from  behind,  since  not  only  the  kidney 
but  also  the  renal  pelvis  is  retroperitoneal.  At  the  hilus  the  pelvis  is  the  most  posterior  struc- 
ture, then  comes  the  artery,  and  anteriorly  is  the  renal  vein  (Fig.  65),  although  variations 
are  sometimes  observed.  This  relation  only  holds  for  the  main  trunks,  the  terminal  divisions 
of  which  are  subject  to  manifold  variations,  so  that  large  arterial  branches  are  often  observed 
to  enter  the  kidney  at  some  distance  from  the  hilus.  In  all  cases,  however,  the  position  of  the 
renal  pelvis,  situated  as  it  is  behind  the  great  vessels,  is  favorable  for  the  removal  of  renal 
calculi  from  behind,  as  the  large  vessels  generally  escape  injury.  Hemorrhage  from  the  renal 
vessels  is  retroperitoneal,  as  a  rule ;  an  intraperitoneal  hemorrhage  must  be  preceded  by  a  lacer- 
ation of  the  peritoneum.  If  the  pelvis  of  the  kidney  becomes  perforated,  the  urine  no  longer 
flows  along  its  normal  channel  in  the  ureter,  but  forms  a  retroperitoneal  urinary  abscess  upon 


Fig.  6j. 


Renal  artery 


Fig.  66. 


Fig.    67. 


Kidney 


Suprarenal  gland 
Kidney 

Splenic  artery 


THE   CONTENTS   OF   THE   ABDOMEN. 


141 


the  qiradratus  lumborum  muscle.  Such  perinephritic  abscesses  and  similar  ones  behind  the 
kidney  may  extend  upward,  affecting  the  pleura  (pleurisy),  or  the  abscess  may  gravitate  to  the 
iliac  fossa  and  pursue  one  of  a  number  of  subperitoneal  courses  similar  to  those  taken  by  a  retro- 
cecal (perityphlitic)  abscess  (see  page  137). 

The  method  of  reaching  the  kidney  from  behind  may  be  discerned  from  a  study  of  Fig.  69. 
An  incision  is  made  along  the  outer  margin  of  the  sacrolumbalis  muscle  (i.  e.,  the  outer  portion 
of  the  iliocostals  of  the  erector  spinae),  extending  from  the  last  rib  to  the  crest  of  the  ilium. 
After  dividing  the  skin,  the  superficial  fascia,  the  latissimus  dorsi  muscle,  and  the  posterior  layer 
of  the  lumbar  fascia,  the  edge  of  the  sacrospinalis  (erector  spinae)  muscle  is  displaced  inward, 


Vertebral  arch- 


Central  canal  of 
vertebra 


Right  kidney 


Vena  cava  inferior 

Liver 

Ascending  colon 

Aorta 

Inferior  mesenteric 

artery 

Pancreas 
Portal  vein 
Intestinal   branches 
of  superior  mesen- 
teric artery 

Gall-bladder 
Duodenum  (de- 
scending portion) 


Latissimus  dorsi 

muscle 
Erector  spins 

muscle 
Quadratus  lumbo- 
rum muscle 
Left  kidney 
Psoas  muscle 
Cartilage  between 
ad  and  3d  lum- 
bar vertebras 
Obliquus  ezternus 

muscle 
Descending  colon 
Small  intestine 


-—Peritoneal  cavity 

—  Trans  versalis  ab- 
dominis muscle 

—  Small  intestine 


Rib 


Rectus  abdominis 
muscle 


Fig.  69. — A  cross-section  of  the  abdomen  in  the  inferior  renal  region 

the  anterior  layer  of  the  lumbar  fascia  is  divided,  and  the  quadratus  lumborum  muscle  is 
exposed.    The  kidney  is  reached  by  dividing  this  muscle  or  by  displacing  its  external  border. 

The  suprarenal  bodies  rest  upon  the  superior  poles  of  the  kidneys.  They  are  also  in  rela- 
tion with  the  crura  of  the  diaphragm.  The  right  suprarenal  capsule,  more  frequently  triangular 
in  shape,  borders  upon  the  liver  [that  is,  upon  the  posterior  surface  of  the  right  lobe.— Ed.]  (im- 
pressio  suprarenalis,  page  131)  and  upon  the  inferior  vena  cava  (Fig.  67) ;  the  left  one  is  in  relation 
with  the  cardia  of  the  stomach. 

The  abdominal  portion  of  the  ureter  extends  from  the  pelvis  of  the  kidney  to  the  ihopectineal 
line  of  the  pelvis  and  is  situated  behind  the  peritoneum.  It  runs  downward  and  somewhat 
inward  upon  the  psoas  muscle,  and  crosses  the  common  iliac  vessels  near  their  bifurcation.  1  he 
ureter  is  placed  in  front  of  the  vessels  and  may  be  easily  exposed  in  this  situation.  The  spermatic 
vessels  are  also  behind  the  peritoneum  and  cross  in  front  of  the  ureter  at  about  the  middle  of  the 


142  TOPOGRAPHIC   AND   APPLIED    ANATOMY. 

psoas  muscle.  During  its  course  the  ureter  describes  a  number  of  slight  but  typical  curves. 
The  descending  portion  of  the  duodenum  lies  upon  the  right  ureter  while  the  duodenojejunal 
flexure  is  superimposed  upon  the  left  one.  The  pelvic  portion  of  the  ureter  is  described  upon 
pages   149  and   151. 

The  Abdominal  Aorta. — The  abdominal  aorta  lies  directly  upon  the  vertebral  column 
and  divides  at  the  fourth  lumbar  vertebra  into  the  two  common  iliac  arteries.  In  thin  individuals, 
when  the  intestines  are  empty,  the  pulsations  of  the  abdominal  aorta  may  be  palpated  through 
the  belly  wall,  particularly  if  lordosis  is  present,  as  this  approximates  the  vertebral  column  to  the 
anterior  wall  of  the  abdomen.  The  pulsations  of  the  aorta  may  also  be  made  palpable  by  tumors 
situated  behind  the  vessel  and  pushing  it  forward.  The  body  of  the  pancreas  crosses  trans- 
versely in  front  of  the  aorta  at  the  level  of  second  lumbar  vertebra;  the  descending  portion 
of  the  duodenum  passes  across  the  vessel  at  a  lower  level.  Below  this  situation  the  aorta  is 
covered  only  by  peritoneum  and  may  be  easily  exposed.  Dilatations  of  the  abdominal  aorta 
(aneurysms)  produce  pressure  symptoms  from  the  neighboring  organs — from  the  intestines, 
from  the  liver,  from  the  biliary  passages,  from  the  kidneys,  and  from  the  ureter  (hydroneph- 
rosis). 

The  common  iliac  artery  extends  to  the  sacroiliac  articulation  and  lies  to  the  inner  side  of 
the  psoas  muscle.  It  is  behind  the  peritoneum  and,  upon  both  sides,  is  situated  in  front  of  and 
somewhat  to  the  left  of  the  corresponding  common  iliac  vein.  It  must  occasionally  be  ligated, 
and  this  may  be  accomplished  without  injury  to  the  peritoneum.  An  incision  is  made  two  centi- 
meters above  and  parallel  to  Poupart's  ligament  (Fig.  81)  through  the  skin,  the  superficial  fascia, 
the  abdominal  muscles,  and  the  transversalis  fascia,  exposing  the  peritoneum,  which  is  pushed 
away  from  the  iliac  fossa  as  the  operator  follows  the  course  of  the  iliac  vessels  upward  behind 
the  peritoneum.  The  external  iliac  artery  is  reached  first  (Fig.  81),  and  then  follows  the  common 
iliac ;  in  the  latter  situation  care  must  be  taken  to  avoid  the  ureter,  which  runs  in  front  of  the 
vessel.  The  incision  must  not  be  extended  too  far  inward,  as  the  inferior  (deep)  epigastric  artery 
would  then  be  endangered  (see  page  121). 

The  Inferior  Vena  Cava. — The  inferior  vena  cava  lies  upon  the  right  side  of  the  abdom- 
inal aorta  (Figs.  61  and  69),  behind  the  ascending  portion  of  the  duodenum  and  the  head  of  the 
pancreas.  Before  its  passage  through  the  foramen  venae  cava?  of  the  diaphragm  it  is  imbedded 
in  the  posterior  margin  of  the  liver  (Fig.  49).  For  a  description  of  the  branches  of  the  inferior 
vena  cava  the  reader  is  referred  to  the  text-books  upon  systematic  anatomy. 

REVIEW  QUESTIONS. 

What  arterial  anastomosis  in  the  anterior  abdominal  wall  may  become  the  chief  collateral  route 
after  an  obstruction  to  the  circulation  in  the  descending  aorta  ? 

How  would  you  draw  a  line  upon  the  external  surface  of  the  abdomen  to  represent  the  course  of  the 
inferior  epigastric  artery  ? 

How  would  you  explain  a  dilatation  of  the  veins  of  the  anterior  abdominal  wall  following  upon  a 
stasis  in  the  region  drained  by  the  inferior  vena  cava? 

What  are  the  effects  of  congestion  of  the  portal  system  in  diseases  of  the  liver  ?  (In  the  anal,  gas- 
tric, and  umbilical  regions.) 


THE   PELVIC  WALLS. 


J43 


What  are  the  relations  of  the  hernial  orifices  of  the  two  main  forms  of  inguinal  hernia  to  the  plica 
epigastrica  ?  What  are  the  relations  of  the  hernial  orifices  of  inguinal  and  femoral  hernia  to  Poupart's 
ligament  ? 

What  practical  conclusions  may  be  deducted  from  the  course  of  the  root  of  the  mesentery  ? 

In  what  three  places  may  the  great  omentum  be  opened  in  order  to  expose  the  pancreas? 

In  what  situation  is  the  stomach  immediately  exposed  upon  opening  the  abdominal  cavity? 

How  is  it  possible  that  after  an  injury  to  the  stomach  the  gastric  contents  may  escape  into  the  left 
pleural  cavity  ? 

What  is  the  explanation  of  fatal  hematemesis  in  a  case  of  gastric  ulcer  ?  How  would  you  explain 
the  expectoration  of  gastric  contents  in  the  same  affection? 

What  relation  explains  the  possibility  of  the  rupture  of  an  hepatic  abscess  into  the  pericardium  ? 

What  is  the  normal  relation  of  the  inferior  border  of  the  liver  to  the  costal  margin  ? 

Into  what  neighboring  organs  may  gall-stones  from  the  gall-bladder  perforate? 

Why  is  it  impossible  to  outline  the  upper  margin  of  the  spleen  by  percussion?  What  renders  it 
impossible  to  locate  the  posterior  margin  by  the  same  method? 

What  is  the  explanation  of  splenic  enlargements  following  upon  venous  congestion  within  the  liver  ? 

What  organs  may  be  perforated  by  an  abscess  of  the  spleen  ? 

In  what  direction  may  ulcers  upon  the  anterior  and  those  upon  the  posterior  wall  of  the  superior 
portion  of  the  duodenum  rupture? 

Where  does  a  perityphlitic  abscess  form  and  in  what  directions  may  it  extend  ? 

Why  are  the  ascending  and  the  descending  colons  adapted  to  the  making  of  an  artificial  anus  from 
behind  ? 

In  what  locations  may  retroperitoneal  hernias  develop? 

Into  what  cavities  may  a  renal  abscess  rupture  when  it  points  upward? 

What  is  the  explanation  of  neuralgic  pains  in  the  thigh  in  tumors  of  the  kidney? 

Into  what  portions  of  the  intestine  may  an  abscess  of  the  right  kidney  perforate? 

Why  is  it  more  practicable  to  attack  the  pelvis  of  the  kidney  from  behind  than  from  in  front  ? 


THE  PELVIS. 
THE  PELVIC  WALLS. 

The  study  of  the  pelvic  region  should  be  preceded  by  a  review  of  the  innominate  bones  and 
of  the  sacrum  as  well  as  by  a  consideration  of  the  bony  pelvis  as  a  whole.  The  following  designa- 
tions, referable  to  the  entire  pelvis,  should  be  thoroughly  understood  by  the  reader:  The  false 
and  true  pelves  (separated  from  each  other  by  the  iliopectineal  line);  the  symphysis  pubis;  the 
sacroiliac  articulation;  the  promontory;  the  acetabulum  with  its  articular  portion  (facies  lunata), 
non-articular  portion  (fossa  acetabuli),  and  cotyloid  notch  (incisura  acetabuli);  the  pubic  angle 
(in  the  male);  the  pubic  arch  (in  the  female);  the  obturator  foramen;  and  the  following  sagittal 
diameters  of  the  pelvis  (Fig.  70) : 

1.  The  anteroposterior  diameter  0}  the  pelvic  inlet  from  the  promontory  to  the  upper  margin 
of  the  symphysis  (conjugata  vera),  about  n.o  centimeters  (4^  inches) ; 


144 


TOPOGRAPHIC    AND    APPLIED    ANATOMY. 


PLATE   19. 
The  male  pelvic  outlet  as  seen  from  without.     From  a  Leipzig  model  from  nature  (His)  with  the  vessels  and  nerves 
sketched  in. 

2.  The  internal  conjugate  diagonal,  measured  in  the  living  subject  from  the  promontory  to 
the  lower  margin  of  the  symphysis  (conjugata  diagonalis),  12.5  centimeters  (5  inches); 

3.  The  anteroposterior  diameter  0}  the  pelvic  cavity  or  the  width  of  the  pelvis,  from   the 
middle  of  the  symphysis  to  the  middle  of  the  third  sacral  vertebra,  12.5  centimeters  (5  inches); 


Fifth  lumbar  verte- 
bra 


First  sacral  vertebra- 
Lateral  sacral  artery  - 
Sacral  canal- 


Great  sacrosciatic -- 
f  oram  en 


Greater  sacrosciatic 

ligament 

Lesser  sacrosciatic 

foramen 

Fifth  sacral  vertebra— 

Lower  sacrosciatic 
ligament 

First  coccygeal  ver 

tebra 


Anterior  superior  spine  of  ilium 


Anterior  inferior  spine  of  ilium 


Symphysis 
Obturator  foramen 


Fig.  70. — A  sagittal  section  of  the  female  pelvis  with  the  anteroposterior  pelvic  diameters.  1,  The  anteropos- 
terior diameter  of  the  pelvic  inlet  (conjugata  vera);  2,  the  internal  conjugate  diagonal  (conjugata  diagonalis);  3, 
the  anteroposterior  diameter  of  the  pelvic  cavity;  4,  the  anteroposterior  diameter  of  the  plane  of  pelvic  contraction; 
5,  the  anteroposterior  diameter  of  the  pelvic  outlet;   A,  the  pelvic  axis  or  curve. 


4.  The  anteroposterior  diameter  of  the  plane  o]  pelvic  contraction,  from  the  lower  margin 
of  the  symphysis  to  the  intervertebral  disc  between  the  last  sacral  and  the  first  coccygeal  vertebra, 
1 1.5  centimeters  (4f  inches); 

5.  The  anteroposterior  diameter  o)  the  pelvic  outlet  from  the  lower  margin  of  the  symphysis 
to  the  tip  of  the  coccyx,  10  to  12  centimeters  (4  to  5  inches).  This  diameter  varies  on  account  of 
the  ability  of  the  coccyx  to  become  displaced  posteriorly. 

The  pelvic  axis  (A  in  Fig.  70)  or  pelvic  curve  is  the  curved  line  which  connects  the  middle 
points  of  the  anteroposterior  diameters. 


'la  I).  19. 


\W 


Os  coAmMB 


l'yril<.niU6  quisle 


Ohltttutw  interou 


iHtfcWMrMMWF 


Is  ■hwu-rnnsusm 

Bulbuo  vestibuli 


.  su  ossium  pubis 
physis 


144 


TOPOGRAPHIC    AND    APPLIED    ANATOMY. 


PLATE    19. 

The  male  peJvic  outlet  as  seen  from  without.     From  a  Leipzig  model  from  nature  (His)  with  tb< 


sketched  in. 


2.  The  internal  conjugate  diagonal,  measured  in  the  living  subject  from  the  | 
the  lower  margin  of  the  symphysis  (conjugata  diagonalis),  12.5  centimeters 

3.  The  anteroposterior  diameter  0}  the  pelvic  cavity  or  the  width   of   th  .  from   the 
middle  of  the  symphysis  to  the  middle  of  the  third  sacral  vertebra,  12.5  a  inches); 

•J 


Fifth  lumbar  verte-  — 
bra 


First  sacral  vertebra  - 


N^ 


»buMa  armolhy'I 


bnh-xi  nmvanaT 
foramen 


Greater  sacrikciatic 
mulu<)«Jt«/L-A 
Lesser  sacros- 
foramen 
Fifth  sacral  vertebrl 

First  co 

-.urn  11  muiilt-I 


ubholib  Haul 
\  sagittal 
terior  pelvic    inl 

the  an1 
5,  the  an: 

aiaydqrax2 


-lumjlni  io)i;iulcl<J 


Ifiiimsin'I 


euaonT' 


uilluM 


4.  The  anteropc  :  pelvic  contraction,  from  er  margin 
of  the  symphysis  to  th.  md  the  first  coccygeal  vertebra, 
1 1. 5  centime; 

5.  The  anteropos, 
to  the  tip  of  the  coccyx,  10  Jo 
the  ability  of  the  coccyx  to  become 

The  pelvic  axis  (A  in  Fig.  7c 
points  of  the  anteroposterior  diameters. 


m  the  lower  margin  of  the 
I  his  iiameter  varies  on 


iich  conne 


TabJSf. 


.- M.  glutaeus  maximus 


Os  coccyges 


M.  piriformis 


Anus. 


M.  obturator^., 
internus 


Trigonum 
urogenital 


Glandula  vestibu- 
laris (Bartholini) 


tf.  bulbocavernosus  -\— 


M.  ischiocavernosus  '       ~"^^^B 
Bulbus  vestibuli 


MJ±.      .M.  sphincter  ant  externum 


_.Lig.  sacrotuberosum 


M.  levator  ani 


Tuber  ischiadicum 


M.  transversus 
perinei 

supcriicialis 


Acetabulum 


Vestibulum  vaginae 
Labium  minus 


Glans  clitoridis 


Symphysis  ossium  pubis 


THE   PELVIC   WALLS.  I4t- 

The  pelvic  inclination  is  the  angle  between  the  conjugata  vera  and  a  horizontal  plane  (about 
60  degrees).  [The  obliquity  of  the  pelvis  varies  in  different  individuals,  is  greater  in  the  female 
than  in  the  male,  and  is  increased  by  hip-joint  disease,  particularly  on  standing.  With  a  normal 
inclination  of  the  pelvis  the  sacral  promontory  is  about  9.5  cm.  (3$  inches)  above  the  upper  border 
of  the  symphysis  and  the  tip  of  the  coccyx  is  %  to  1  inch  above  its  lower  border.— Wolsey.]  From 
a  practical  standpoint,  it  will  be  noted  that,  owing  to  the  pelvic  inclination,  a  wound  passing 
through  the  abdominal  wall  horizontally  above  the  symphysis  may  involve  the  filled  bladder, 
the  uterus,  and  the  rectum,  parts  which  are  protected  posteriorly  by  the  bony  pelvic  wall  (the 
sacrum). 

The  true  pelvis,  our  "first  path  in  life,"  and  of  more  practical  importance  than  the  false 
pelvis,  is  accessible  in  the  female  to  the  examining  finger  or  to  the  entire  hand,  which  may  be 
introduced  into  the  vagina  for  diagnostic  or  operative  purposes.  It  commences  above  at  the  pelvic 
inlet  or  superior  aperture  of  the  pelvis;  the  plane  of  this  aperture  passes  through  the  iliopectineal 
line  and  is  directed  anteriorly;  it  is  open  below  at  the  smaller  cordiform  pelvic  outlet  or  inferior 
aperture  of  the  pelvis.  The  plane  of  the  latter  is  curved,  the  concavity  being  directed  upward,  since 
it  descends  from  the  symphysis  to  the  tuberosities  of  the  ischium  and  then  ascends  to  the  tip  of 
the  coccyx  (compare  the  two  pelvic  apertures  to  the  two  apertures  of  the  thorax,  see  page  92). 
The  form  of  the  pelvic  canal  is  that  of  a  truncated  and  inverted  cone  or  funnel.  The  anterior 
wall  of  the  pelvic  canal  is  formed  by  the  symphysis,  by  the  two  pubic  rami  (horizontal  and 
descending),  and  by  the  ascending  ramus  of  the  ischium.  The  large  obturator  foramina  are 
closed  by  the  obturator  membranes,  only  the  small  obturator  canal  being  left  open  above  and 
internally.  The  lateral  walls  are  formed  by  the  acetabular  portion  of  the  innominate  bone,  by 
the  body  and  descending  ramus  of  the  ischium,  and  by  the  greater  and  the  lesser  sacrosciatic 
ligaments.  The  posterior  wall  corresponds  to  the  sacrum  and  coccyx  and  is  markedly  concave 
anteriorly.  The  coccygeal  vertebras  are  connected  by  discs  of  fibrocartilage  which  render  them 
movable,  particularly  in  a  posterior  direction,  as  may  be  observed  during  the  evacuation  of  a 
mass  of  hardened  feces  and  during  labor.  The  obstetrician  is  consequently  justified  in  regarding 
an  ankylosis  of  the  coccygeal  vertebras  as  a  cause  of  difficult  delivery. 

The  portions  of  the  pelvis  which  may  be  palpated  externally  are  the  posterior  surfaces  of 
the  sacrum  and  coccyx,  the  tuberosities  of  the  ischium,  the  iliac  crests,  the  anterior  superior 
spines  of  the  ilium,  and  the  symphysis  pubis.  The  portions  which  may  be  palpated  from  the 
vagina  and  from  the  rectum  are  the  concave  inner  surfaces  of  the  sacrum  and  of  the  coccyx, 
the  ischium,  the  pubis,  and  the  pelvic  surface  of  the  acetabulum. 

Fractures  of  the  pelvic  walls  are  not  infrequently  associated  with  injuries  to  the  organs 
situated  within  the  pelvis,— the  urinary  bladder,  the  urethra  (particularly  in  the  male),  the 
rectum,  the  great  vessels,  and  the  sacral  plexus. 

The  bony  framework  of  the  pelvis  is  strengthened  by  ligaments,  muscles,  and  fascias,  which 
better  adapt  it  to  protect  the  enclosed  viscera,  vessels,  and  nerves.  The  greater  and  lesser 
sacrosciatic  ligaments  strengthen  the  lateral  pelvic  wall  and  aid  in  the  formation  of  the  greater 
and  lesser  sacrosciatic  foramina.  The  pyrijormis  muscle  arises  from  the  anterior  surface  of 
the  sacrum,  passes  out  of  the  pelvis  through  the  greater  sacrosciatic  foramen,  and  inserts  into 
the  great  trochanter.     The  foramen  is  almost  entirely  closed  by  the  muscle,  so  that  above  and 


146  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

PLATE   20. 
The  female  pelvic  outlet  as  seen  from  without.     From  a  Leipzig  model  from  nature  (His). 

* 

below  the  pyriformis  there  are  only  narrow  spaces,  the  suprapyrijorm  and  infrapyrijorm  foramina, 
through  which  important  vessels  and  nerves  make  their  exit  from  the  pelvis.  The  lesser  sacro- 
sciatic  foramen  gives  passage  to  the  obturator  internus  muscle,  which  arises  from  the  inner 
surface  of  the  obturator  membrane  and  its  immediate  vicinity  and  inserts  into  the  great  tro- 
chanter. In  the  upper  and  inner  portion  of  the  obturator  membrane  there  is  a  small  opening, 
the  obturator  canal,  through  which  the  obturator  artery  and  nerve  leave  the  pelvis  and  through 
which  the  obturator  vein  enters  it. 

At  the  pelvic  outlet  there  is  stretched  a  funnel-shaped  musculo-tendinous  plate,  the  dia- 
phragma  pelvis.  The  chief  portion  of  the  pelvic  diaphragm  is  formed  by  the  levator  ani  muscle. 
It  arises  from  the  white  line  (arcus  tendineus)  in  the  obturator  fascia,  which  extends  from  the 
posterior  surface  of  the  horizontal  ramus  of  the  pubis  to  the  spine  of  the  ischium.  In  the  male 
the  muscle  is  inserted  into  the  rectum  and  into  the  prostate;  in  the  female,  into  the  rectum 
and  into  the  vagina.  The  closure  of  the  inferior  pelvic  aperture  is  completed  anteriorly  by  the 
musculo-tendinous  plate  of  the  diaphragma  urogenitale  (trigonum  urogenitale),  triangular  liga- 
ment, which  is  stretched  across  the  pubic  arch.  In  the  male  the  urogenital  diaphragm  gives 
passage  to  the  membranous  portion  of  the  urethra ;  the  muscular  tissue  surrounding  the  urethra 
in  this  situation  is  known  as  the  compressor  urethra?  muscle.  This  septum  is  also  perforated 
by  the  deep  veins  of  the  penis  which  enter  the  corpora  cavernosa.  In  the  female  it  gives  passage 
to  the  vagina  as  well  as  to  the  urethra. 

The  pelvic  diaphragm  divides  the  larger  superior  from  the  smaller  inferior  portion  of  the 
pelvis.  The  former  is  the  direct  continuation  of  the  abdominal  cavity  and,  as  it  contains  the 
pelvic  viscera,  it  may  be  called  the  visceral  portion  of  the  pelvic  space.  The  abdominal  viscera  are 
also  found  in  this  deepest  portion  of  the  peritoneal  space,  but  they  are  kept  out  of  the  pelvis 
to  a  greater  or  less  extent  by  the  amount  of  space  required  by  the  pelvic  viscera.  The  extra- 
visceral  portion  of  the  pelvic  space  is  situated  below  the  pelvic  diaphragm  and  between  it  and 
the  inferior  portion  of  the  lateral  pelvic  wall  (the  ischium  and  the  overlying  obturator  internus 
muscle) ;  it  is  filled  with  fat  and  forms  the  ischiorectal  jossas. 

In  the  extravisceral  portion  of  the  pelvic  space  the  terminal  portions  of  the  viscera  passing 
through  the  pelvic  diaphragm  are  surrounded  by  the  clamp-like  musculature  which  renders 
possible  the  opening  and  the  closing  of  the  particular  visceral  canal. 

The  external  sphincter  ani  muscle  surrounds  the  terminal  portion  of  the  rectum  in  a  circular 
manner.  The  superficial  fibers  run  from  before  backward  to  insert  into  the  tip  of  the  coccyx. 
Anteriorly  the  fibers  are  continuous  with  the  bulbocavernosus  muscle  in  the  male  and  with  the 
constrictor  cunni  *  muscle  in  the  female.  [According  to  Cunningham,  the  most  superficial  fibers 
of  the  external  sphincter  ani  decussate  in  front  of  and  behind  the  anus;  the  deepest  fibers  are 
arranged  in  a  circular  direction  around  the  canal,  while  between  these  the  bulk  of  the  muscular 
fibers  are  attached  posteriorly  to  the  coccyx,  anteriorly  to  the  central  tendon  of  the  perineum, 
reducing  the  empty  canal  to  an  anteroposterior  slit  on  horizontal  section. — Ed.]     The  bulbo- 

*  The  sphincter  vagina:. 


vinttniaF  pudfc  «rt«f  a#?^eWls 
Interior  hemorrhoidal  artery 


Aa.  scrotales  postenc 

Superficial  perineal  arteries 


M.  ischiocavernosus 
Ischiocavernosus 


GMcygemtyfreua 


Superficial  periniMtl  ivrv< 

Corpus  oivrrnosurn 


. 


At<i.il'uluni 


Corpus  s|Hingiosum 


t '  r  J .  l  t 


PLATB   20. 
.  from  without. 


ire  only  narro 
Is  and  nei 

;  the  obturator  m 

In  the  upper  an  turator  memi 

ator  canal,  through  rator  arter}'  and  nerve'  leav 

h  the  obturator  vein  entei 

At  the  pelvic  outlet  thereJ3W:>s\retched^a  funnel-shap&d  mu 
phragma  pelvis.     Tht"^"r?W^i^ion/<tfTne  penac  diaphragm  is*"iorv 
It  arises  from  the  ^'bj^Jluie  (amis  teVlineus)  V  the  obturator  fascKu  ^ 
posterior  surface  of  the  horiz^rtal\arnu\of  the  pubis  to  the  spine  of  th\ischium. 


the  muscle  is  inwrttc 
and  into  the  vagina.  " 
muscuiontentiiftfMiB 
jnWfiJttUiiHtebiis_st 

■ 


liexectihn  and  into  the  prostate;    in  the  ferKale,  into  th 
uffcof  the  inferior  pelvic  aperture  is  completed  anteriorly 
of  trrts^/o'  \i  urogeniiale  (trigonunr  urogennale" 

the  pntiic  arch.     In  the  m .L^emtal  dYTpfiragm  gi 

ius  portion  of  the  uretii^a;  the  muscular  tissue  surrounding  Jhfijjiisfttiuf&orxiui 


■■ 


YTjJ-JC 


passage  to  the 

in.m^  >*i-is  known  astlre^-corm  pressor  urethrae  muscle.     This  septwrTisalV.  rated 

by  th     yr    veins  of  tne*p««s^vhich  entertrre^corpora  cavernosa.     In  the  female  it  eivj  s X--.  i*>nmq 

to  the/agina  as  well  as  to  the  uretnni 

'he  pelvic  diaphragm  divides  the  larger  superior  from  the  smaller  inferior  portion  of  the 
pelvis.     'I  mation  of  the  abdominal  cavity  and,  as  it  contain 

V  .7  portion  of  thepfekqcspace.     The  abdominal  viscera  are 

\  /  "^-^^  are  kept  out  of  the  p 

\              pBMcyiscera.    The  i 
''clow  th\      ^\^iaphragr  \^  ^   . 

hiurrnand  th-   \^  

\         /  C»f»t1«<tsWbKIliSQdlU|l 


sua*trr>v . 




in  a  circi  and  th 

attached 
the  empty  Canal  to  ai 


7U.20. 


\    et  Vt.  pudendae  internae 
A.  haemorrhoidalis  inferior. 

Tuber  ischiadicum._ 


A.  perinei 


M.  bulbo-cavernosus. 

Aa.  scrotales  posteriores 


Os  coccygis 

M.  coccygeus 

M.  levator  ani 


M.  piriformis 


,N.  pudendus 
Anus 

M.  obturator  interims 


M.  sphincter 
ani  externus 


M.transversus 

perinei 

superficialis 


J 


Acetabulum 
-  M.  obturator  externum 


M.  ischiocavernosus 


--->Nn.  scroUles  posteriores 
Corpus  cavernosum  penis 

Corpus  cavernosum  urethrae 


THE   PELVIC   CAVITY   IN   THE   MALE.  147 

cavernosus  muscle  arises  from  a  tendinous  raphe*  commencing  at  the  anus;  its  fibers  diverge 
anteriorly,  surround  the  bulb  of  the  urethra,  and  run  to  the  corpora  cavernosa  of  the  penis. 
The  constrictor  cunni  muscle  radiates  anteriorly  from  the  anus,  covers  the  bulbi  vestibuli,  sur- 
rounds the  entrance  of  the  vagina,  and  runs  over  the  dorsum  of  the  clitoris.  The  ischiocavernosus 
muscle  arises  from  the  anterior  margin  of  the  ascending  ramus  of  the  ischium,  covers  the  corpus 
cavernosum  penis  (or  clitoridis),  and  radiates  to  the  lateral  and  dorsal  surfaces  of  the  penis  (or 
clitoris).  The  superficial  transversus  perinei  muscle  varies  greatly  in  different  individuals;  it 
runs  from  the  descending  ramus  of  the  ischium  to  the  median  line,  where  it  becomes  continuous 
with  its  fellow  of  the  opposite  side  and  with  the  bulbocavernosus  muscle. 

It  should  be  clearly  understood  that  chronic  inflammations  in  the  posterior  pelvic  wall, 
particularly  those  in  the  region  of  the  sacroiliac  articulation,  may  extend  posteriorly  to  the  sacral 
and  the  lumbar  regions,  anteriorly  to  the  pelvic  space,  from  which  they  may  pass  inward  to  the 
rectum,  to  the  bladder,  or  to  the  uterus,  downward  through  the  pelvic  diaphragm  to  the  ischio- 
rectal fossa,  or  posteriorly  through  the  sacrosciatic  foramina  beneath  the  gluteal  muscles.  Sup- 
purations originating  in  the  pelvic  viscera  (for  example,  in  the  prostate,  in  the  seminal  vesicles, 
and  in  that  portion  of  the  urethra  situated  above  the  urogenital  diaphragm)  may  pass  downward 
through  the  diaphragm,  reach  the  ischiorectal  fossa,  and  then  perforate  the  skin  near  the  anus. 
The  so-called  periproctitic  abscesses,  originating  independently  in  the  fat  of  the  ischiorectal 
space,  may  also  point  in  the  same  situation,  and,  under  certain  circumstances,  such  abscesses 
may  be  felt  as  swellings  through  the  rectal  wall  by  the  finger  introduced  into  the  anus. 

The  vessels  and  nerves  of  the  pelvic  space  should  be  recalled  to  memory  by  the  aid  of  a  text- 
book of  systematic  anatomy.  The  branches  of  the  internal  iliac  artery  in  the  male  and  in  the 
female,  and  the  lumbar  and  sacral  plexuses  with  their  respective  branches,  should  also  be  re- 
viewed. 

THE  PELVIC  CAVITY  IN  THE  MALE. 
The  Urinary  Bladder.— The  male  urinary  bladder  (Plate  21),  when  distended,  takes 
up  the  greater  portion  of  the  pelvic  cavity.  It  is  in  relation  with  the  anterior  pelvic  wall.  Its 
position  varies  with  the  state  of  distention,  since  the  full  bladder  extends  particularly  upward 
and  backward,  although  it  also  enlarges  laterally.  When  empty,  it  barely  extends  above  the 
upper  margin  of  the  symphysis;  while  when  extremely  distended,  it  may  reach  almost  to  the 
navel,  compressing  and  displacing  the  small  intestines  situated  posterior  to  the  viscus.  It  con- 
sequently follows  that  when  it  is  desired  to  enter  the  bladder  above  the  symphysis,  by  puncture, 
for  example,  the  rule  is  to  previously  distend  the  bladder  artificially  to  avoid  the  danger  of 
entering  the  peritoneal  cavity  (see  page  127).  By  this  route,  calculi  and  tumors  may  be  removed 
from  the  bladder  and  the  urethra  may  be  catheterized  (catheterismus  posterior)  (retrograde 
catheterization).  The  internal  orifice  of  the  urethra  is  situated  in  the  median  line  about  three 
centimeters  behind  the  middle  of  the  symphysis.  [According  to  Cunningham,  the  posterior 
opening  of  the  urethra  is  slightly  below  the  level  of  and  from  2  to  2  J  inches  behind  the  upper 
border  of  the  symphysis.  It  is  easily  reached  through  a  suprapubic  wound.— Ed.]  The  inferior 
wall  of  the  bladder  rests  upon  the  prostate  gland.  The  anterior  surface  is  connected  to  the 
pelvic  wall  by  loose  connective  tissue  which  allows  the  distended  bladder  to  ascend  into  the 


148  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

PLATE   21. 
A  median  sagittal  section  of  the  male  pelvic  region.     From  a  Leipzig  model  from  nature  (His). 

Fig.  71. — The  bladder,  the  ureters,  and  the  seminal  vesicles  exposed  from  behind  by  a  frontal  section  of  the  pelvis. 
Upon  the  left  side  there  is  an  external  inguinal  hernia;  upon  the  right  side  the  peritoneum  has  been  almost  entirely 
removed. 

supravesical  space  (cavum  Retzii),  which  is  situated  above  the  symphysis  and  also  is  filled  with 
loose  connective  tissue.  The  superior  surface  is  directed  upward  and  backward  and  borders 
upon  the  small  intestine  and  the  sigmoid  colon.  In  contrast  to  the  anterior  surface,  it  possesses 
a  peritoneal  reflection  (see  Fig.  71,  in  which  a  part  of  this  reflection  is  still  present)  which  passes 
above  the  symphysis  to  reach  the  inner  surface  of  the  abdominal  wall.  Since  the  height  of 
the  bladder  above  the  symphysis  is  inconstant  and  varies  with  the  degree  of  distention  of  the 
viscus,  it  follows  that  the  line  of  reflection  of  the  peritoneum  from  the  abdominal  wall  to  the 
bladder  is  also  inconstant,  and  is  higher  or  lower  according  to  whether  the  bladder  is  full  or 
empty.  If  the  peritoneum  is  irritated  by  an  inflammation,  peritoneal  pains  will  be  produced 
by  the  displacement  of  the  peritoneum  during  urination.  The  larger  portion  of  the  lateral 
surfaces  is  also  covered  by  peritoneum,  which  extends  downward  over  the  ligamentum  urn- 
bilicale  laterale  (see  page  123).  The  posterior  and  inferior  surfaces  rest  upon  the  sacral  curve 
of  the  rectum  (see  page  150).  The  posterior  surface,  at  least  in  its  upper  portion,  possesses 
a  peritoneal  reflection.  For  this  reason  a  rupture  of  the  posterior  wall  of  the  bladder  is  a  more 
serious  injury  than  one  of  the  anterior  wall,  since  the  former  may  at  once  involve  the  peritoneum 
and  almost  surely  produce  a  fatal  peritonitis  unless  the  surgeon  interferes  in  time.  Between  the 
bladder  and  the  rectum  the  peritoneum  forms  the  excavatio  rectovesical.  Below  the  line  of 
the  reflection  of  the  peritoneum  from  the  bladder  to  the  rectum  the  posterior  wall  of  the  bladder 
is  separated  from  the  anterior  wall  of  the  rectum  by  a  loose  connective  tissue,  and  the  rectovesical 
fascia,  which  also  passes  to  the  inferior  surface  of  the  bladder  (in  the  region  of  the  fundus). 
The  seminal  vesicles  (Plate  21  and  Fig.  71)  are  imbedded  in  this  tissue  and,  when  well  developed, 
may  extend  upward  as  far  as  the  line  of  reflection  of  the  peritoneum  from  the  bladder  to  the 
rectum.  Between  the  seminal  vesicles  are  the  ends  or  ampullas  of  the  vasa  deferentia  which 
unite  with  the  ducts  of  the  seminal  vesicles  to  form  the  ejaculatory  ducts.  These  parts  as  well 
as  the  fundus  of  the  bladder  (and  occasionally  vesical  calculi),  from  their  relation  to  the  anterior 
rectal  wall,  are  accessible  to  digital  examination  from  the  rectum.  This  is  also  most  valuable 
in  the  examination  of  the  bladder,  of  the  prostate  (particularly  when  hypertrophied),  and  of 
the  seminal  vesicles,  the  contents  of  which  may,  under  certain  circumstances,  be  emptied 
through  the  urethra  by  pressure  upon  the  anterior  rectal  wall. 

The  relation  0}  the  rectum  to  the  bladder  may  be  utilized  in  practice  by  filling  the  rectum 
with  water,  or  by  tamponade,  in  order  to  force  the  distended  bladder  forward  and  upward 
toward  the  anterior  abdominal  wall  and  thus  render  it  more  accessible  to  operative  procedures 
above  the  symphysis.  [The  reflections  of  peritoneum  from  the  bladder  to  the  anterior  walls 
of  the  pelvis  and  abdomen  and  to  the  lateral  walls  of  the  pelvis  rise  higher  and  higher  according 
to  the  degree  of  distention.  As  pointed  out  by  the  author,  the  reflection  from  the  bladder  to 
the  rectum — posterior — however,  changes  but  little.  This  reflection  takes  place  at  the  level 
of  about  one  inch  above  the  prostate  or  a  finger's  length  from  the  anus.     A  knowledge  of  this 


Jab.  2 I 


21 


Intestii^gji  jftaftg. 


M.  rectiaeofe 


Ves7ci»aiyrfchddi» 


Orificiu 


Symphysis   e  s.siuiSvrfliM^fc. 
Lie.  su"Sw«9«flmi^,p»'iitf 


CiBnhydbiracucTcl  <if  moihru 
urethrae 
Corpus   cav&KBWiWepWW 

Pars  6»*wnwi»o»if*rtwUwa 


Corp«tr^ft%p^0MMI 
urethrae 


Mmmm 


—  -1-rfeaSftPf  torium 


ulslifclsacralis 


Bulb  of 


sSiSfBgU-of^' 


rftaMtata 

HwNtoT  ^ft-ulatori  ut 


i.r.i   tSItrMM 


T«U%eia9e#ai<QpUiid.vmi8 
BiMt^WttM^vernosus 


TOPOGRAPHIC    A' 


A  median  sagittal  section  of  the  m 
i   —The  bladder,  the  ureter 


Upon  the  left   side  there  is  an  externa 
ed.  tt. 


lur 


i  above  tl       t 


I 


nr*  rs 
I 


supravesical  space  (cavum  I 

loose  connective  tissue.  e  is  directed  i 

upon  the  small  intestine  <  i*moid  colon.     In  contrast  to  i  he  ante; 

a  peritoneal  reflectioWtSW^  r  ■•vhich  a  part  oi  this  reflection  is  still 

above  the  symphysis  to  reac  i  the  inner  surface  of  the  abdominal  wall.      Sii 

the  bladder  above  ihetogfttt-p  .v&Ls  is  inconstant  and  varies  with  the  degree  <> 

viscus,  it  follows  that  the  lire  of  reflection  of  the  peritoneum  fiuni  llie  abdominal 

bladder  is  also  inconstant,  ajid  is  higher  or  lower  according  to  whether  the  bladdej^-^   / 

empty.     If  the  peritoneum  ii  irritated  by  an  inflammation,  peritoneal  painsjjaH^be  prod|< 

bv  the  displacement  of  the  peritoneum  during  urination.     The  larger^^tfrtion  of  the  lafetaL,, 

surfaces  is  also  covered  by  peritoneum,  which   extends  downwarcWver  the   ligamentum  Jum- 

bilicale  laterale  (fce&ngfigfcflaw! — The  posterior  and  inferior>«rftaces  rest  upon  the  sacral  t urve 

of  the  rectum  (see  page  150).!   The  posterior  surface,  at  least  in  its  upper  portion,  possesses 

a  peritoneal  reflection.     For  thk  reason  a  rupture  of  the  posterior  wall  of  the  bladder  is  I  more 

serious  injury  than  one  of  the  aAterior  wall,  since  the  former  may  at.nnrr  invnlvr  tho  ppyfnffi*1^*11"" 

and  almost  surely  produce  a  fatal  peritonitis  unless  the  surgeon  interferes  in  time.     Bc/veftBi-jUift  -»aho  fun 

— : ^  /  ^■i-viiiimy'. 

ler  and  the  reottHfwi^hggperitoncuiii  fun  us  the  extdvalio  rectovesical  it. — btfluw  lhe-foitt,ifofcji 

rectum-4he  posterior  wall  of  tftc-  btoaocp""  ^ 


the  reflection  of  the  perifolf 


Wl 


T 

mi 

re 

ui 

as 

re 

in  t 

the 

throui. 

with  water,  or  b) 

toward  the  anterior  al 

above  the  symphysis.     [Th 

of  the  pelvis  and  abdomei 

to  the  degree  of  distention. 

the  rectum — posterior — however,  cr 

of  about  one  inch  above  the  prostat 


£iriJ'Jii' 


d  from  trffknterTo^wLll  of  the1  legtum  bv  a  loo>e  connective  tissue,  and  the  r\ 

\  '    ■  _  I        irnl)-n»   ' 

ich  alsanftas&BBiiiUK  iiv   suifiut1  of  The  bladder  (in  the  region  01  meiiunch 

'\r  -  7T)»i*  imlnj.lihiil  In  llii^Ttmir  inil  nlirn  wrlT-rlf-r  ■***> 

\  1     ■•(  tion  of  the  peritoneum  from  the.  hlinh/ir1.^.,Jil>gnoinoq  <g 


the  ends  or  ampullas  of  the  vasa  deferemtia  which 

I        \  ' 

\ 


— 


1 

this 


Tab.2t. 


Mesenterium 


Intestinum  tenue 


M.  rectus  abdominis 


Vesica  urinaria 


Orificium  urethrae  internum 
Symphysis  ossium   pubis 
Lig.  suspensorium  penis 
V.  dorsalis  penis 

Curvatura    subpubica 
urethrae 
Corpus  cavernosum  penis 

Pars  cavernosa  urethrae 


Corpus  cavernosum 
urethrae 


Promontorium 


Canalis  sacralis 


Flexura  sacralis  recti 


Vesicula  seminalis 
.  Prostata 

Ductus  ejaculatorius 

Flexura  perinealis  recti 
Glandula  bulbourethral  (Cow 

Curvatura   postpubica 
urethrae 


M.  sphincter 
ani  externus 


Glaus  penis 


Bulbus  urethrae  Testis  et  epididymis 

M.  bulbocavernosus 


Fig.  7;. 


Peritoneum 
M    'lop«oas  Deep  ep;eastric  vesSeI 

j  External  inguinal   hernia 


Internal  iliac  artery 
Ureter 


Acetabulum 


M.  obturator  int 

Seminal  vesicle 


Ampulla  of  vas 
deferens 


;  External  umbilical  ligament 
Obturator  artery 
Obturator  nerve 


THE   PELVIC   CAVITY  IN  THE  MALE.  I49 

was  much  more  important  formerly,  when  it  was  the  practice  to  enter  the  bladder  by  puncture 
through  the  anterior  rectal  wall,  than  now,  when  such  a  procedure  is  rarely,  if  ever  permissible 
The  posterior  surface,  fundus  or  base  of  English  writers,  and  the  pubic  surface  are  scarcely 
changed  by  any  degree  of  distention.— Ed.] 

The  Ureter.-The  pelvic  portion  of  the  ureter  (Fig.  71),  after  crossing  the  iliopectineal 
line,  runs  beneath  the  peritoneum  in  the  lateral  pelvic  wall  along  the  internal  iliac  artery;  it 
then  passes  inward  and  forward  to  the  fundus  of  the  bladder,  being  crossed  by  the  vas  deferens, 
which  passes  backward  and  inward  [i.  e.,  the  vas  crosses  on  the  vesical  side  of  the  ureter.— Ed.].' 
The  Male  Urethra.— In  the  flaccid  penis  the  urethra  forms  an  S-shaped  curve  and  is 
fifteen  to  twenty  centimeters  in  length.  The  first  or  postpubic  curve  is  situated  behind  the 
symphysis  and  its  concavity  is  directed  forward  and  upward.  This  curve  must  always  be  borne 
in  mind  during  the  introduction  of  a  catheter,  sound,  or  cystoscope  for  the  purpose  of  diagnosis, 
irrigation,  or  internal  illumination  of  the  bladder  (cystoscopy),  since  it  does  not  disappear  when 
the  penis  is  elevated.  The  second  or  subpubic  curve  is  situated  beneath  the  symphysis,  its 
concavity  is  directed  downward  and  backward,  and  it  disappears  upon  elevation  of  the  penis. 
The  urethra  is  subdivided  into  three  portions— the  prostatic,  the  membranous,  and  the  spongy 
(pars  prostatica,  membranacea,  and  cavernosa  urethrae).  The  urethra  possesses  three  wide 
and  two  narrow  places : 

The  three  wide  places  are:  (1)  The  pars  prostatica;  (2)  the  recessus  bulbosus,  a  dilatation 
situated  in  the  commencement  of  the  pars  cavernosa,  which  may  occasionally  catch  the  end  of 
the  catheter;  and  (3)  the  jossa  navicularis,  just  behind  the  external  orifice. 

The  narrow  portions  of  the  urethra  are:  (1)  The  pars  membranacea,  the  muscular  wall  of 
which  opposes  the  introduction  of  an  instrument  by  reflex  contractions;  and  (2)  the  meatus, 
behind  which  small  calculi  may  become  impacted  after  they  have  escaped  from  the  bladder. 
[It  is  worth  noting  that,  in  normal  urethras,  an  instrument  which  passes  the  external  meatus 
may  be  expected  to  pass  the  other  narrowed  portions  without  difficulty. — Ed.]  The  internal 
orifice  of  the  urethra  is  also  not  infrequently  narrowed  and  causes  difficulty  in  urination,  par- 
ticularly when  the  middle  lobe  of  an  hypertrophied  prostate  presses  against  the  orifice.  [The 
effect  of  enlargement  of  the  middle  lobe  of  the  prostate  is  to  create  a  bar  behind  the  urethra 
and  to  so  change  the  relation  that  the  bladder  opening  of  the  urethra  does  not  correspond  to  the 
lowest  level  of  that  organ,  as  it  should;  the  result  is  that  the  bladder  cannot  be  completely 
emptied,  more  or  less  urine  remaining — residual  urine.  It  also  changes  the  length  and  curve 
of  the  prostatic  urethra,  which  must  be  remembered  in  attempting  to  catheterize  these  cases. — 
Ed.]  From  the  relation  of  the  prostate  to  the  rectum  it  will  be  understood  that  prostatic  inflam- 
mations and  abscesses  may  extend  posteriorly  and  break  into  the  rectum.  The  chief  seat  of 
urethral  stricture  is  at  the  junction  of  the  cavernous  with  the  membranous  portions.  From 
the  study  of  a  median  sagittal  section  it  will  be  clear  that  the  retained  and  decomposing  urine 
above  the  stricture  may  give  rise  to  inflammation  and  suppuration  which  may  perforate  into 
the  rectum,  into  the  scrotum,  or  through  the  perineum.  It  should  also  be  noted  that  the  urethra 
may  be  opened  by  making  an  incision  in  the  perineal  raphe,  in  the  median  line,  and  dividing 
the  skin,  the  tunica  dartos,  the  superficial  perineal  fascia,  the  bulbocavernosus  muscle,  and 
the  bulbus  urethra?.     Finally,  it  should  not  be  forgotten  that  in  gonorrhea  the  anatomic  rela- 


150  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

tions  are  very  favorable  for  an  extension  of  the  process  internally  along  the  urethra  and  an 
involvement  of  the  entire  genito-urinary  apparatus. 

The  Rectum. — The  rectum  lies  behind  the  bladder  and  runs  from  the  promontory  to  the 
anus  in  a  double  curve.  The  first  or  long  curve  corresponds  to  the  hollow  of  the  sacrum,  and 
is  known  as  the  sacral  curve  (flexura  sacralis).  It  extends  to  the  tip  of  the  coccyx  and  to  the 
prostate,  and  the  concavity  of  the  curve  is  directed  anteriorly.  The  second  or  short  curve  is 
in  the  perineum  {flexura  perinealis) ;  it  is  convex  anteriorly,  only  about  three  centimeters  in 
length,  and  is  surrounded  by  the  external  sphincter  ani  muscle.  A  knowledge  of  these  curves 
is  important  for  operative  procedures  and  for  the  introduction  of  the  rectal  speculum.  The 
rectum  also  deviates  from  the  median  line  in  some  cases,  but  to  so  slight  a  degree  that  the 
variation  is  of  no  practical  importance.  The  narrowest  portion  of  the  rectum  is  its  termination, 
which  is  surrounded  by  the  sphincters.  Just  above  this  is  a  dilatation,  the  ampulla  recti,  which 
is  particularly  developed  posteriorly.  The  posterior  wall  of  the  rectum  is  attached  to  the 
sacrum  by  loose  connective  tissue  in  which  are  situated  a  number  of  lymphatic  glands.  These 
glands  extend  upward  to  the  sacroiliac  articulation;  in  cases  of  rectal  carcinoma  they  become 
involved  and  must  be  removed.  In  this  neighborhood  there  is  also  a  large  number  of  veins 
which  anastomose  with  the  venous  hemorrhoidal  plexus  surrounding  the  anus.  The  perineal 
curve  borders  anteriorly  upon  the  prostate  gland.  At  this  point  rectal  carcinoma  may  extend 
to  the  prostate,  the  prostate  may  be  treated  surgically  through  the  anterior  rectal  wall,  and 
prostatic  hypertrophy  and  calculi  situated  in  the  fundus  of  the  bladder  may  press  upon  the 
rectum  and  render  defecation  difficult. 

The  sacral  curve  may  be  subdivided  into  two  sections.  The  inferior  one  is  situated  below 
the  rectovesical  fold  and  is  consequently  not  covered  by  peritoneum.  It  borders  anteriorly 
upon  the  fundus  of  the  bladder,  the  ampullas  of  the  vasa  deferentia,  and  the  seminal  vesicles; 
these  parts  may  therefore  be  involved  by  the  extension  of  a  rectal  carcinoma.  In  this  situation 
the  bladder  may  be  entered  from  the  rectum  without  opening  the  peritoneal  cavity.  Only  the 
anterior  surface  of  the  lower  end  of  the  superior  portion  of  the  sacral  curve  is  covered  by  peri- 
toneum ;  higher  up  the  lateral  surfaces  are  also  covered,  while  at  the  promontory,  the  peritoneum 
almost  completely  surrounds  the  rectum  and  fixes  it  to  this  point  by  a  short  mesorectum.  In 
operating  high  up  in  the  rectum  it  must  be  remembered  that  the  danger  of  opening  the  peritoneal 
cavity  increases  as  we  ascend.  The  distance  between  the  deepest  point  of  the  rectovesical  fold 
and  the  anus,  measured  along  the  anterior  rectal  wall,  is  about  six  to  eight  centimeters.  The 
situation  in  which  the  rectum  possesses  a  lateral  peritoneal  reflection  is  from  twelve  to  fourteen 
centimeters  above  the  anus.  From  the  relation  of  the  rectum  to  the  sacrum  it  will  be  seen  that 
this  portion  of  the  intestine  may  also  be  attacked  from  behind  after  the  resection  of  a  portion 
of  the  sacrum. 


THE  PELVIC  CAVITY  IN  THE  FEMALE. 

The  essential  difference  between  the  relations  of  the  pelvic  viscera  in  the  two  sexes  is  due 
to  the  fact  that  the  male  genitalia  take  up  less  space  and  are  situated  almost  entirely  outside  of 
the  pelvis.     In  the  female,  however,  the  ovaries,  the  tubes,  the  uterus,  and  the  vagina  are  pushed 


Inte8t>srtH»  ibsm 


M.  rect«Kc*b4f»MMfe 


CoqM^usuten 
Fu*aw&u*jtfarri 

Cerr»viHt«eH 
Symphysis  ossiumv 

Vesica  urttifWtf 


i-Uju      tmn.H. 


22 


.spm»ld««ah»craki 


Ampulh  of  rwtufn 
ESlenisf  Sj'!iinc!cr  ani 


EJi'^wii^skiM''18'1" 


i5o 


TOPOGRAPH 


are  very  favorable  for  an  ex1 
•nt  of  the  entire  genito-urin 
The  Rectum. — The  rectum  li<  aontorv 

anus  in  a  double  curve.     The  first  or  long  cun  sacrum,  and 

the  sacral  curve  (flexura  sacralis).     It  extends  to  th<  and  to  the 

ate,  and  the  concavity  of  the  curve  is  directtd  anteriorly.     Th<  curve  is 

in  the  perineum  {flexura  perinealis);    it  is  convex  anteriorly,  only  abou 

u,  and  is  surrounded  by  the  external  sphincter  ani  muscle.     A  knowlecu  arves 

is  important  for  operative  procedures  and  for  the  introduction  of  the  rectal 
rectum  also  deviates  from  the  median  line  in  some  cases,  but  to  so  slight  a  d< .  i 

variation  is  of  no  practical  importance.  The  narrowest  portion  of  the  rectum  is  its  ten  1 
which  is  surround<ftj,j,bfoo&e  sphincters. — Just  abovo  this  io  a  dilatation,  the  ampulla  recti,  i 
is  particularly  de^^te^wP  puslerioily.     The  posterior  wall  of   the  rectum  is  attached  tb  the 


sacrum  by  loose  connective 

glands  extend  upward  to  tl 

involved  and  must  be  re 

which  anastomose  with  the^ 

curve  borders  anteriorly  upAnN^the  prostate  gland 

to  the  prostate,  the  prostat  i 

prostatic  hypertrophy  and 

rectum  and  render  defecati 

The  sacral  «46itf»rmWi 
the  rectovesical  fold  and  is 
the  fundua-i<efrafcll«y 
parts  may  therefore  be  ifcvob 


issue  in  \\Jn^iua*e^ituated  a  number  of  lymphatic  glands 
iliac  articulation;  in  cases  of  rectal  carci 
In  this  neighborhood  there  is  also  a  large  numtj 
uSSiemorrhoidal  plexus  surrounding  the^a«Trs\ 
At  this  point-rectal  carcino 


"hese 
[come.  J 

.  .1111  muiic 


ins 
rineal 

fir 

y  be  treated  surgically  through  the  antenafrectai  wall,  and 

alcul\situate4  in  the  fundus  of  the  bladcjer  may  press  upon  the 

difficult. 

divided  into  two  sections 
nsequ£n1    ^Trot-GOi^red  by   peritoneum.     It    borders  antjbriorlv 


Tlie   inferior  one  it  situated 


oLxfi;  eul'jaSl 


h'liu  tuqyoD 


btkiW "  ^ubnu'i 


ampullas  of  the  vasa  delerentia,  and  th< 
Y  erf  ti  rectal  carcinoma. 


ra3 


t             ider  may  be  entered  from  the  rectum  without \op ening  *]->*  p^rit^n^i  /-avity 
,  A>fc-jiU«iii(»rtUi-i — \ — — -nrt.iLn  of  ♦'•":  snrrr'1  nir'"p  ;*  rnvprj 


\     \        ;e  at  the  promontory,  thpperitoneum 

\  \    |  '    mesNfr'rfiim  ,..„;U, 


.p&Ufl 

In  this  situation 
bv  nfamn'f 


in  the  rectum 


must  be  rem 


ti 

s 

i 

this  port: 

of  the  sacrum. 


\ 


\ 


\ 
I 

|  •  i 

Iso  be  at  rtion 


THE  PELVIC  CAVITY  IN  THE  FEMALE. 

The  essential  differen  en  the  rel  in  the  tw  3  due 

to  the  fact  that  the  male  genitalia  take  up  les  entirely  01 

the  pelvis.     In  the  female,  however,  the  ova ri  ^hed 


Tab.22. 


Promontorium 
Canalis  sacralis 


Vertebrae 

sacrales 


Orificium  internum  uteri 
-Vertebrae  coccvgeae 

Ampulla  recti 
M.  sphincter  ani  externus 


Portio  vaginalis  (cervicis) 


Fig.  72. 


Fallopian  tube 


Fundus   uteri  --- 


Ovarian   vessels 


Broad   ligament 


Urinary  bladder 


Urethra 


Ovary 


Suspensory  ligament  of  ovary 


Ovarian  vessels 

Round  ligament 
Internal  iliac  artery 

Ureter 
Uterine  arterv 


.  Round  ligament 


Peritoneum 


THE   PELVIC   CAVITY   IN   THE   FEMALE. 


151 


PLATE  22. 
A  median  sagittal  section  of  the  female  pelvic  region.     From  a  Leipzig  model  from  nature  (His). 
Fig.  72.— The  relation  of  the  ureter  to  the  uterine  artery  and  to  the  cervix  and  vagina.     The  left  half  of  a  speci- 
men in  which  a  median  section  of  the  female  pelvic  viscera  has  been  made.     The  broad  and  round  ligaments  have  been 
incised  and  the  uterus  displaced  upward  and  backward. 


in,  as  it  were,  between  the  bladder  and  rectum,  and  almost  entirely  surrounded  by  a  peritoneal 
duplicature,  the  ligamentum  latum  (broad  ligaments). 

The  Bladder.— The  capacity  of  the  female  bladder  is  about  one-fourth  less  than  that  of 
the  male.  The  position  of  the  viscus  behind  the  anterior  pelvic  wall  and  its.  relation  to  the 
peritoneum  are  about  the  same  as  in  the  male.  The  posterior  wall  of  the  bladder,  however, 
has  quite  a  different  topography  on  account  of  the  presence  of  the  uterus  and  the  vagina.  The 
larger  part  of  the  bladder  (that  is,  of  the  base  or  fundus)  rests  upon  the  upper  portion  of  the 
anterior  vaginal  wall  (Plate  22);  the  top  of  the  bladder  borders  upon  the  cervix  uteri.  The 
uterus  and  the  bladder  are  united  by  a  loose  connective  tissue,  but  between  the  bladder  and  the 
vagina  the  connective  tissue  forms  a  tense  layer,  the  vesicovaginal  septum.  The  connection 
between  the  anterior  cervical  wall  and  the  posterior  surface  of  the  bladder  is  so  firm,  however, 
that  the  uterus  promptly  follows  the  movements  of  the  posterior  vesical  wall  produced  by  the 
varying  degree  of  distention  of  the  viscus.  The  peritoneum  covers  the  bladder  above  and  behind, 
as  far  as  the  middle  of  the  posterior  surface,  from  which  situation  it  is  reflected  upon  the  uterus 
at  the  junction  of  the  body  with  the  cervix,  forming  the  vesico-uterine  fold  (excavatio  vesico- 
uterina).  It  will  be  observed  that  the  bladder  may  be  opened  through  the  anterior  vaginal  wall, 
without  injuring  the  peritoneum,  for  the  purpose  of  removing  foreign  bodies  (calculi)  and  pal- 
pating the  interior  of  the  viscus.  The  bladder  may  also  be  opened  above  the  pubis  (sectio  alta), 
as  in  the  male,  for  the  treatment  of  vesical  tumors  or  tuberculosis. 

The  Ureter. — As  the  ureter  of  the  female  enters  the  true  pelvis,  it  crosses  the  origin  of  the 
external  iliac  vessels  and  runs  downward  to  the  outer  side  [in  front  of. — Ed.]  of  the  internal  iliac 
artery.  It  then  crosses  over  the  origin  of  the  uterine  artery  and  passes  to  the  inner  side  of  this 
vessel  (Figs.  72  and  73).  In  the  neighborhood  of  the  cervix  the  uterine  artery  is  usually  very  tor- 
tuous (perhaps  as  a  result  of  a  past  pregnancy  ?)  and  passes  inward  over  the  ureter  to  ascencl  upon 
the  body  of  the  uterus.  Very  close  to  this  crossing  the  artery  usually  gives  off  a  good-sized  branch, 
the  ramus  cervicovaginalis.  The  ureter  is  imbedded  in  loose  connective  tissue  alongside  of  the 
cervix.  At  the  level  of  the  anterior  lip  of  the  cervix  the  ureters  approach  the  vaginal  wall  and 
empty  into  the  bladder  somewhat  below  the  external  orifice  of  the  uterus.  This  relation  of  the 
ureter  must  be  remembered  by  the  operator  (in  vaginal  hysterectomy,  for  example),  since  the 
ureter  is  not  infrequently  divided  in  this  situation.  During  its  course  in  the  true  pelvis  the  ureter 
is  occasionally  exposed  to  compression  from  uterine  or  ovarian  tumors,  so  that  retention  of  the 
urine  in  the  ureter  and  in  the  kidney  with  its  manifold  sequelae  is  possible.  [According  to  Cun- 
ningham, the  ureter  near  its  termination  is  about  f  of  an  inch  external  to  the  lateral  aspect  of 
the  cervix  uteri. — Ed.] 

The  Urethra.— The  female  urethra  is  but  three  centimeters  in  length.  It  is  wider  than  in 
the  male  and  so  capable  of  dilatation  that  the  interior  of  the  bladder  may  be  palpated  through 
the  urethra  by  the  average  finger.     In  consequence  of  the  greater  width  and  of  the  shorter  length, 


152  TOPOGRAPHIC   AND    APPLIED   ANATOMY. 

fair-sized  vesical  calculi  may  be  removed  through  the  urethra  in  the  female  more  easily  than 
in  the  male.  Its  coarse  is  almost  directly  forward  and  downward  with  an  insignificant  anterior 
concavity.  The  urethra  rests  upon  the  lower  portion  of  the  anterior  vaginal  wall,  from  which 
it  is  separated  by  the  comparatively  broad  urethrovaginal  septum.  The  narrowest  place  is  at  the 
external  orifice,  where  the  urethra  opens  as  a  sagittal  slit  into  the  vestibulum  vaginae. 

The  Uterus. — The  body  of  the  uterus  projects  toward  the  peritoneal  cavity  between 
the  bladder  and  the  rectum;  it  is  very  movable  and  its  position  is  continually  influenced 
by  the  degree  of  distention  of  the  bladder  and  of  the  rectum.  Disregarding  its  fixation 
to  the  vagina,  bladder,  and  peritoneum  (ligamentum  latum),  the  uterus  is  held  in  its 
position  chiefly  anteriorly  by  the  ligamentum  teres  passing  into  the  inguinal  canal  and 
posteriorly  by  the  recto-uterine  muscles  situated  within  the  folds  of  Douglas.  The  anterior 
surface  of  the  body  of  the  uterus  rests  upon  the  bladder,  although  it  is  separated  from 
it  by  the  vesico-uterine  fold  of  peritoneum  (excavatio  vesico-uterina).  When  the  bladder  is 
full,  it  raises  the  uterus  to  a  vertical  position;  when  the  bladder  is  empty,  the  uterus  sinks 
anteriorly.  The  empty  and  the  full  rectum  have  a  similar  influence  upon  the  position  of  the 
uterus.  The  neck  of  the  uterus  is  more  fixed,  and  in  such  a  way  that  the  external  os  is  usually 
at  the  level  of  the  upper  margin  of  the  symphysis  and  the  longitudinal  axis  of  the  cervix  corre- 
sponds to  the  pelvic  axis  (see  page  144).  Since  the  highest  point  of  the  fundus  uteri  does  not 
extend  to  the  plane  of  the  pelvic  inlet,  it  follows  that  the  normal  non-pregnant  uterus  is  always 
entirely  within  the  true  pelvis.  The  fixation  of  the  cervix  is  due  to  its  attachment  to  the  vagina, 
to  the  connective  tissue  between  it  and  the  bladder,  and  to  the  recto-uterine  muscles,  which  are 
enclosed  in  the  recto-uterine  folds  of  the  peritoneum  and  run  to  the  lateral  walls  of  the  rectum 
and  to  the  sacrum.  The  position  of  the  uterus  in  the  dead  body  is  no  criterion  for  that  in  the 
living  woman.  The  normal  position  is  an  inclination  anteriorly  with  a  more  or  less  decided 
angle  between  the  cervix  and  the  body  (normal  anteflexion)  which  is  influenced  by  the  distention 
of  the  bladder.  If  no  angulation  is  present,  so  that  the  longitudinal  axes  of  the  body  and  of 
the  cervix  form  a  straight  line,  we  speak  of  anteversion;  this  condition  tends  to  be  more  or  less 
prevalent  after  repeated  pregnancies.  In  the  dead  subject  the  uterus  is  usually  displaced  pos- 
teriorly, chiefly  because  gravitation  has  a  better  chance  to  act  on  account  of  the  relaxed  mus- 
culature and  of  the  absence  of  the  intra-abdominal  tension.  Retroversion  and  retroflexion  are 
always  abnormal  positions. 

The  Peritoneum. — The  peritoneum  is  reflected  from  the  bladder  to  the  uterus  at  the  level 
of  the  internal  os,  forming  the  vesico-uterine  fold  (excavatio  vesico-uterina),  passes  over  the  fundus 
and  covers  the  posterior  surface  of  the  uterus  as  far  as  the  upper  portion  of  the  vagina  and  is 
reflected  to  the  rectum,  forming  the  recto-uterine  fold  (excavatio  recto-uterina).  The  peritoneum 
is  firmly  adherent  to  the  posterior  surface  of  the  uterine  body,  but  it  is  more  loosely  attached  to 
the  cervix.  This  relation  of  the  peritoneum  is  of  great  importance  for  operative  procedures  upon 
the  uterus  and  upon  the  vagina.  It  is  clear  that  the  anterior  wall  of  the  cervix  may  be  incised 
toward  the  bladder  without  danger  of  opening  the  peritoneal  cavity,  while  an  incision  into  the 
posterior  wall  may  easily  open  the  peritoneal  cavity.  We  may  also  incise  the  anterior  vaginal 
wall,  work  upward  in  the  loose  connective  tissue  between  the  cervix  and  the  bladder,  and  open 
the  vesico-uterine  pouch  to  reach  the  genital  organs  within  the  peritoneal  cavity.     For  the  same 

• 


FiS-  71- 


External  iliac  vein 
External  iliac  artery;:   Lymphatic  glands 
Ovarian  vessels 


Abdominal  orifice  of 
Fallopian   tube 


Ampulla  of  Fallopian 
tube 

Suspensory  ligament 
of  ovary 


Ovary  • 


Isthmus  of  Fallopian  tube  ■ 
Superior  vesical  artery  ■ 
Uterine  artery 


Fundus  uteri 


•  Common  iliac  vein 

-  Promontory 

-  Internal  iliac  artery 

-  Ureter 

-First  sacral  vertebra 
-Obturator   nerve 

-Obturator  artery 

-External  umbilical  lig. 

-Broad  ligament 
-Sciatic  artery 

Internal  pudic  artery 

Uterine  vein 


M.  recto-uterinus 


Rectum 


THE  PELVIC   CAVITY  IN  THE  FEMALE.  T53 

♦h.  c-JIGV  ll~ T^  1ftCral  ^u  W^.°f  the  female-     The  P°sterior  layer  of  the  broad  ligament  has  been  incised  at 
tt:n°lX7^£XPOUCh-     ^  UtemS'  **  ^  ^  aDd  °~*  haS  ^  disPlaced  ^riorly  and  £Z&Z 


purpose  the  gynecologist  opens  the  peritoneal  cavity  by  incising  the  posterior  vaginal  fornix 
and  entering  the  recto-uterine  pouch.  In  a  general  way  this  procedure  is  the  easier  one,  since 
it  is  not  necessary  to  first  separate  the  cervix  from  the  bladder. 

The  Vagina.— The  vagina  runs  from  above  and  behind  obliquely  downward  and  forward. 
Its  course  presents  a  slight  concavity  anteriorly  and  it  forms  an  inconstant  angle  with  the  cervix, 
which  is  usually  a  right  angle  in  the  virgin.  The  anterior  vaginal  wall  is  somewhat  shorter  than 
the  posterior  one,  chiefly  because  the  posterior  wall  extends  higher  upon  the  cervix  than  does 
the  anterior  one.  The  vaginal  vault — i.  e.,  the  circular  portion  of  the  vagina  surrounding  the 
intravaginal  cervix— is  lower  anteriorly  than  posteriorly,  where  the  fornix  is  deeper  and  where 
the  vaginal  cervix  is  longer.  Although  the  anterior  Up  of  the  cervix  is  shorter  than  the  posterior 
one,  it  is  situated  at  a  lower  level. 

The  anterior  wall  of  the  vagina  borders  upon  the  bladder  (with  the  interposition  of  loose 
connective  tissue)  and  upon  the  urethra  (where  the  connective  tissue  is  firmer).  It  is  conse- 
quently easy  to  enter  the  bladder  through  the  anterior  vaginal  wall.  Upon  the  posterior  vaginal 
wall  we  differentiate  three  areas  (Plate  22): 

1.  A  small  superior  one,  the  region  of  the  posterior  vaginal  vault.  This  portion  has  a 
peritoneal  reflection  and  is  in  relation  with  the  deepest  point  of  the  recto-uterine  pouch. 

2.  A  middle  area,  the  longest  of  the  three,  which  borders  upon  the  sacral  curve  of  the  rectum. 
It  is  separated  from  the  rectum  by  the  rectovaginal  septum,  which  is  composed  of  loose  connective 
tissue  and  favors  the  prolapse  of  the  vagina  and  of  the  uterus. 

3.  A  short  inferior  area,  where  the  rectum  becomes  more  distant  from  the  vagina  on  account 
of  its  perineal  curve.  It  is  situated  below  the  urogenital  diaphragm,  and  the  perineum  separates 
this  portion  of  the  vagina  and  its  vestibule  from  the  lower  end  of  the  rectum.  In  this  situation 
a  slight  perineal  tear  during  delivery  may  lead  to  a  laceration  of  the  wall  of  the  vestibule  of  the 
vagina,  together  with  a  varying  amount  of  trauma  to  the  perineal  tissue  and  to  the  skin.  If 
the  tear  is  a  complete  one,  the  anterior  wall  of  the  rectum  will  also  be  lacerated. 

What  is  the  result,  however,  of  a  greater  dilatation  with  laceration  or  of  ulcerative  processes 
higher  up  in  the  vagina  ?  They  lead  to  the  formation  of  fistulas  or  to  abnormal  communications 
between  the  viscera.  Anteriorly,  there  may  be  a  urethrovaginal  fistula  between  the  urethra  and 
the  vagina,  higher  up  there  will  be  a  vesicovaginal  fistula,  and  still  higher  a  vesicocervical  fistula. 
In  any  of  these  conditions  the  urine  will  continually  dribble  from  the  vagina  in  a  most  troublesome 
manner.  Posteriorly,  a  rectovaginal  fistula  may  develop  and  feces  may  be  passed  through  the 
vagina.  Since  the  upper  vaginal  wall  and  the  cervix  are  in  relation  with  the  ureters  (see  page 
151),  it  is  possible  to  have  a  ureterovaginal  or  a  ureterocervical  fistula. 

The  Ovaries.— The  position  of  the  ovaries  in  the  true  pelvis  is  partially  disclosed  by  the 
designation  of  the  parts  of  these  flat  ellipsoidal  bodies.  We  differentiate  an  external  and  an 
internal  surface,  a  superior  and  an  inferior  pole  (extremitas  tubaria  and  extremitas  uterina), 
and  an  anterior  and  a  posterior  margin  (margo  mesovaricus  and  margo  liber).  The  anterior 
margin  corresponds  to  the  hilus  of  the  ovary,  where  the  vessels  make  their  entrance  and  exit. 


154  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

The  longitudinal  diameter,  which  connects  the  tubal  with  the  uterine  pole  of  the  ovary,  is  almost 
vertically  placed;  the  external  surface  is  in  immediate  contact  with  the  lateral  pelvic  wall,  at 
the  level  of  the  pelvic  inlet,  close  to  the  inner  border  of  the  psoas  muscle.  The  suspensory 
ligament  of  the  ovary  (ligamentum  infundibulopelvicum)  runs  from  the  lateral  pelvic  wall  to  the 
superior  or  tubal  pole  and  transmits  the  ovarian  vessels  to  the  ovary  (Fig.  72).  Posteriorly  the 
ovary  is  in  relation  with  the  ureter  and  the  uterine  artery,  above  and  anteriorly  it  borders  upon 
the  remains  of  the  hypogastric  artery  (ligamentum  umbilicale  laterale).  The  position  of  the  ovary 
is  not  absolutely  fixed  and  is  often  abnormally  influenced  by  inflammatory  processes  in  the 
neighborhood.  The  gynecologist  should  be  able  to  palpate  the  ovary  by  bimanual  examination 
through  the  vagina  and  the  anterior  abdominal  wall,  in  which  procedure  the  vaginal  finger 
reaches  chiefly  the  uterine  pole  and  the  internal  surface  of  the  viscus. 

The  Fallopian  Tube. — The  Fallopian  tube  is  situated  in  the  free  border  of  the  broad  liga- 
ment and  cannot  pursue  a  straight  course  in  the  restricted  confines  of  the  true  pelvis.  We 
differentiate  three  portions  of  its  course :  The  first  portion  or  isthmus  passes  horizontally  outward 
from  the  uterus  to  the  uterine  pole  of  the  ovary;  the  second  portion  makes  a  right  angle  with 
the  first  and  runs  upward  from  the  anterior  margin  of  the  ovary  to  its  superior  pole ;  after  making 
another  acute  turn,  the  third  or  terminal  portion  runs  backward  and  downward  and  terminates 
at  the  ostium  abdominale,  which  is  directed  toward  the  posterior  free  margin  of  the  ovary. 

The  Rectum. — In  the  female  the  rectum  has  the  same  curves  as  those  described  in  the  male. 
Its  anterior  wall  is  in  relation  with  the  uterus  (the  recto-uterine  pouch  being  interposed)  and 
the  vagina;  the  cervix  may  be  palpated  through  this  wall  by  the  finger  introduced  into  the 
rectum.  The  rectovaginal  septum  is  composed  of  loose  areolar  tissue  and  is  predisposed  to  the 
formation  of  rectovaginal  fistulas  after  marked  distention  and  laceration  of  the  vagina. 

REVIEW-  QUESTIONS. 

How  may  the  bladder  be  entered  anteriorly  without  injuring  the  peritoneum? 

Why  are  injuries  of  the  anterior  wall  of  the  bladder  (such  as  a  rupture,  for  example)  less  dangerous 
than  those  of  the  posterior  wall  ? 

From  what  situation  may  we  palpate  and  operate  upon  the  bladder  (in  the  male),  the  prostate 
gland,  and  the  seminal  vesicles? 

How  does  the  enlargement  of  the  prostate  gland  affect  the  internal  orifice  of  the  urethra? 

To  what  height  may  we  operate  upon  the  anterior  rectal  wall  without  endangering  the  integrity 
of  the  peritoneal  cavity  ? 

To  what  parts  may  a  carcinoma  of  the  rectum  extend  anteriorly? 

From  what  situation  may  the  posterior  wall  of  the  bladder  be  opened  in  the  female? 

Which  wall  of  the  cervix  may  be  incised  without  danger  of  opening  the  peritoneal  cavity,  and  in 
which  wall  does  this  danger  exist? 

What  is  the  relation  of  the  inferior  extremity  of  the  ureter  to  the  vagina  ? 

What  peculiarity  of  the  female  urethra  is  of  importance  from  a  practical  standpoint? 

Is  it  easier  to  enter  the  peritoneal  cavity  through  the  anterior  or  through  the  posterior  vaginal 
vault  ? 

What  has  happened  when  urine  dribbles  from  the  cervix  or  from  the  vagina,  and  what  when  feces 
escape  through  the  vagina? 


F'g-  74- 


F'S-  15- 


Symphysis 
pubis 


Anterior  superior 
spine  of  ilium 


Iliofemoral  ligament 

Great  trochanter  Iliofemoral 

lliopectineal  bursa  ligament 

"Pubocapsular  ligament  Great  trochanter      . 

Ischiocapsular  Ischiocapsular  J; 

ligament  ligament 

Lesser 
trochanter 


Iliac  crest 
Anterior  superior  spine  of  ilium 


M.  iliopsoas 
Anterior  crural   nerve 

Poupart's  ligament      _ 
lliopectineal  fascia 

lliopectineal  eminence , 

Femoral  artery M-V-l 

Femoral  vein 

Femoral  ring 
Crest  of  pubis 
Gimbernat's  ligament  __ 
Spine  of  pubis 

A 


Fig.  76. 


Articular  surface  of  acetabulum 


Fossa  of  acetabulum 


Bodv  of  ischium 


Tuberosity  of  ischium 


Descending  ramus  of  pubis  Obturator      Xscending  ramus  of  ischium 

foramen 


THE   REGION    OF   THE   HIP. 


J55 


Fig.  74— A  diagrammatic  representation  of  an  anterior  view  of  the  hip-joint.  The  attachment  of  the  capsular 
ligament  corresponds  to  the  linea  intertrochanterica  (red).  The  weaker  portions  of  the  capsule  are  colored  yellow 
A  detailed  description  will  be  found  in  the  text. 

Fig.  75.— A  diagrammatic  representation  of  a  posterior  view  of  the  hip-joint.  The  attachment  of  the  capsular 
ligament  (red  line)  is  situated  above  the  intertrochanteric  crest.  The  weak  areas  in  the  posterior  portion  of  the  capsule 
are  colored  yellow. 

Fig.  76. — A  diagrammatic  representation  of  the  lacuna  musculorum,  of  the  lacuna  vasorum,  and  of  the  femoral 
ring. 


What  part  of  the  uterus  may  be  palpated  through  the  anterior  wall  of  the  rectum  ? 
Where  may  we  palpate  the  ovaries? 


THE  LOWER   EXTREMITY. 

In  accordance  with  the  fact  that  the  lower  extremity  is  considerably  larger  than  the  upper 
one,  we  find  that  the  vessels  and  the  nerves  of  the  leg  are  much  larger  than  those  of  the  arm, 
for  which  reason  amputations  and  resections  in  the  lower  extremity  are,  in  general,  much  more 
serious  operations  than  the  corresponding  procedures  in  the  upper  extremity,  and  wounds  of 
the  lower  extremity  are  also  generally  more  dangerous  than  those  of  the  upper  extremity.  The 
greater  distance  of  the  lower  extremity  from  the  heart  is  also  in  harmony  with  the  fact  that,  as 
compared  with  the  arm,  there  is  a  greater  tendency  to  the  development  of  ulcers,  chronic  skin 
diseases,  edema,  and  dilatation  of  the  veins  from  the  unfavorable  influence  of  gravitation. 
As  the  motions  of  the  joints  are  more  restricted  than  is  the  case  in  the  upper  extremity,  we 
find  that  dislocations  in  this  situation  are  of  more  infrequent  occurrence. 

THE  REGION  OF  THE  HIP. 

The  boundary  between  the  lower  extremity  and  the  trunk  is  furnished  anteriorly  by  the 
crease  of  the  groin,  which  runs  from  the  anterior  superior  spine  of  the  ilium  to  the  region  of  the 
symphysis  and  corresponds  in  its  direction  to  that  of  Poupart's  ligament.  Posteriorly  the  boun- 
dary-line coincides  with  the  iliac  crest,  since  the  gluteal  region  belongs  to  the  lower  extremity. 
The  gluteal  region  terminates  below  at  the  well-marked  gluteofemoral  crease,  at  the  inner  ex- 
tremity of  which  may  be  felt  the  tuberosity  0}  the  ischium.  Anteriorly  the  crease  of  the  groin 
separates  the  inguinal  region  from  the  subinguinal  region.  Midway  between  the  symphysis  and 
the  anterior  superior  spine  of  the  ilium  may  be  felt  the  pulsations  of  the  femoral  artery  which 
passes  beneath  Poupart's  ligament.  In  spare  individuals  this  artery  may  be  seen  pulsating. 
The  lymphatic  glands  situated  in  the  subinguinal  region  (Fig.  77)  are  palpable  only  when 
abnormally  enlarged.  Upon  the  outer  side  of  the  hip  the  great  trochanter  may  be  felt  beneath  the 
skin;  below  this  point  the  femur  is  entirely  surrounded  by  muscles.  When  the  thigh  is  flexed 
to  a  right  angle,  the  tip  of  the  great  trochanter  lies  beneath  a  line  running  over  the  buttock  and 
connecting  the  anterior  superior  spine  of  the  ilium  with  the  tuberosity  of  the  ischium  (Roser- 
Nelaton's  line).  Changes  in  the  position  of  the  trochanter  (in  dislocations  and  diseases  of  the 
hip- joint)  may  be  recognized  with  the  aid  of  this  line. 


156  TOPOGRAPHIC   AND   APPLIED   ANATOMY. 

The  Hip- joint. — The  range  of  motion  at  the  hip  is  much  more  restricted  than  that  of  the 
shoulder  and  it  is  consequently  much  more  rarely  the  seat  of  traumatic  luxations.  Its  position 
is  defined  in  the  living  subject  by  the  aid  of  a  line  drawn  from  the  anterior  superior  spine  of  the 
ilium  to  the  symphysis;  a  line  drawn  at  right  angles  to  its  middle  point  strikes  the  center  of  the 
acetabulum  (Fig.  74).  The  joint  is  formed  by  the  head  of  the  femur  and  the  acetabulum  of 
the  innominate  bone.  The  central  or  non-articular  portion  of  the  acetabulum  is  not  covered 
by  cartilage  and  is  known  as  the  fossa  acetabuli;  this  fossa  is  surrounded  by  the  articular  portion, 
which  is  covered  by  cartilage  and  is  known  as  the  fades  lunata.  The  head  of  the  femur  is  covered 
by  cartilage  with  the  exception  of  the  fovea  capitis,  to  which  is  attached  the  ligamentum  teres. 
This  ligament  has  a  broad  origin  from  the  fossa  acetabuli  and  carries  vessels  to  the  head  of 
the  femur.  It  is  therefore  possible  that  after  a  complete  intracapsular  fracture  of  the  neck  the 
head  will  not  undergo  necrosis,  but  that,  after  becoming  adherent  to  the  socket,  a  false  joint 
is  usually  formed.  The  acetabulum  is  further  deepened  at  its  margin  by  the  cotyloid  ligament 
(labrum  glenoidale),  which  also  bridges  over  the  cotyloid  notch  (incisura  acetabuli)  as  the  trans- 
verse ligament.  The  capsular  ligament  arises  from  the  innominate  bone  outside  of  the  labrum 
glenoidale,  so  that  the  free  border  of  this  structure  lies  within  the  joint.  Anteriorly  it  is  attached 
to  the  intertrochanteric  line  of  the  femur;  posteriorly,  however,  the  ligament  is  inserted  at  a 
higher  level  at  the  middle  of  the  femoral  neck  (see  the  dotted  red  line  in  the  diagrammatic  Figs. 
74  and  75).  The  trochanters  are  outside  of  the  joint.  It  is  particularly  important  to  note  that 
the  anterior  surface  of  the  neck  is  entirely  within  the  joint,  while  only  the  superior  portion  of 
the  posterior  surface  is  intracapsular.  Variations  occasionally  occur.  The  relation  of  the  cap- 
sular attachment  explains  the  fact  that  fractures  of  the  neck  of  the  femur  are  sometimes  entirely 
intracapsular,  and  sometimes  intracapsular  anteriorly  but  extracapsular  posteriorly — the  so- 
called  mixed  fractures.  It  is  extremely  rare  for  one  of  these  fractures  to  be  entirely  extracapsular. 
The  capsule  is  reinforced  by  three  ligaments : 

1.  The  iliofemoral  ligament.  This  ligament  is  situated  anteriorly,  arising  from  a  point 
below  and  beside  the  anterior  inferior  spine  of  the  ilium  and  inserting  into  the  intertrochanteric 
line.     It  is  very  strong  and  is  never  lacerated  in  dislocations  of  the  joint. 

2.  The  pubocapsular  ligament,  from  the  body  of  the  pubic  bone  to  the  region  of  the  trochanter 
minor. 

3.  The  ischiocapsular  ligament,  from  the  body  of  the  ischium  to  the  anterior  surface  of  the 
great  trochanter.  Between  these  stronger  portions  of  the  capsule  are  three  weak  places  (indi- 
cated in  the  diagrams  by  yellow),  which  indicate,  as  it  were,  the  preformed  places  of  exit  for 
the  femoral  head  in  the  different  forms  of  dislocation.  The  posterior  luxations  (the  iliac  and 
the  sciatic)  occur  at  the  posterior  weak  area,  the  anterior  ones  (obturator,  infrapubic,  and  supra- 
pubic) find  their  way  out  through  the  thin  portions  of  the  capsule  situated  anteriorly  and  inter- 
nally. [The  weakest  portion  of  the  capsule  of  the  shoulder  is  below,  while  that  of  the  hip  is 
behind.  Hence  downward  and  forward  dislocations  (76  per  cent.)  are  more  frequent  in  the 
former  and  backward  and  upward  in  the  latter  (hip- joint). — Eisendrath.]  The  thin  portions 
of  the  capsule  are  also  important  for  the  paths  along  which  articular  effusions  tend  to  reach 
the  surface.  Upon  the  anterior  weak  area,  between  the  iliofemoral  and  pubocapsular  ligaments, 
there  is  a  large  bursa,  the  iliopectineal  bursa,  which  frequently  (once  in  ten  cases)  communicates 


Fig.  77. 


Superficial  epigastric 

artery 
Superfic.  epigastr.  vein 

Superficial  circumflex 

iliac  artery 

Superficial  circumflex 

iliac  vein 


Femoral  vein 


Lymphatic  gland 
(enlarged) 


External  abdominal 

ring 
Spermatic  cord 


Falciform  margin 

(saphenous  opening) 

„  External  pudic  veins 

External  pudic 
arteries 


Fig.  78. 


M.  obliquus  ext.   abdominis 
Iliac  branch  of  iliohypogas- 
tric nerve 


M.  glutaeus  minimus 

M.  glut,  maximus 
Superior  gluteal  nerve 
Gluteal  artery 

M.  piriformis 

Inferior  gluteal  nerve 
Sciatic  artery 

Internal  pudic  artery 

Pudic  nerve 
Comes  nervi  ischiadici     -  -*/&i^\ 

Great  sacrosciatic   lig, 

Small  scia,tic  nerve 
Great  sciatic  nerve 

Tuberosity   of  ischium    - 

M.  semitendinosus 

M.  biceps 

M.  semimembranosus 


M.  glutaeus 
medius 


M.  gemellus  sup. 

M.  obturator  int. 
Great  trochanter 
M.  gemellus  inf. 
M.  glutaeus  max. 

M.   quadratus  fe- 

moris 
Trochanteric    bursa 
of  m.  glut.   max. 


M.  adductor 
niagnus 


Superior  perfora- 
ting artery 


THE   REGION  OF   THE  HIP.  jey 

Fig.  77.— The  subinguinal  region  with  the  vessels  and  lymphatic  glands  lying  upon  the  deep  fascia. 
Fig.  78. — The  topography  of  the  deep  gluteal  region. 


with  the  joint.  Pus  occasionally  escapes  from  the  joint  by  this  route  and  passes  beneath  the 
psoas  muscle;  an  iliac  abscess  may  pass  beneath  Poupart's  ligament  and  enter  the  joint  at  this 
point,  and  with  particular  ease,  of  course,  when  there  has  been  a  previous  communication  between 
the  bursa  and  the  joint. 

As  the  femoral  vessels  and  the  anterior  crural  nerve  are  almost  immediately  in  front  of  the 
joint,  they  are  frequently  involved  by  articular  affections  (for  example,  by  pressure  from  an 
anterior  dislocation);  posteriorly  the  sciatic  nerve  (see  page  161)  is  also  occasionally  indicated 
in  affections  of  the  joint. 

The  muscles,  the  vessels,  and  the  nerves  pass  beneath  Poupart's  ligament  from  the  iliac 
fossa  and  reach  the  anterior  surface  of  the  thigh  according  to  a  typical  topographic  arrangement 
(Fig.  76).  This  is  particularly  of  practical  importance  toward  the  symphysis  on  account  of 
the  occasional  occurrence  of  femoral  hernia,  which  escapes  beneath  Poupart's  ligament,  in 
contradistinction  to  the  inguinal  variety,  which  passes  out  from  the  abdomen  above  this  structure 
through  the  external  abdominal  ring  (see  page  124).  The  iliopsoas  muscle  passes  to  the  thigh 
beneath  the  outer  portion  of  Poupart's  ligament,  accompanied  by  the  anterior  crural  nerve, 
and  covered  by  the  iliac  fascia  (Fig.  76).  The  fascia  is  adherent  to  the  ligament  as  it  passes 
beneath  this  structure,  but  it  subsequently  follows  the  surface  of  the  muscle  inward  and  is 
attached  to  the  iliopectineal  eminence.  From  this  point  the  fascia  passes  over  the  pelvic  margin 
to  the  thigh  and,  as  the  iliopectineal  fascia,  follows  the  iliopsoas  and  pectineus  muscles  behind 
the  femoral  vessels  and  forms  the  so-called  deep  layer  (pubic  portion)  of  the  fascia  lata.  To 
the  inner  side  of  the  iliopsoas  muscle  and  its  fascia  there  is  left  a  second  space  beneath  Poupart's 
ligament,  which  extends  toward  the  symphysis  as  far  as  Gimbernat's  ligament  (f,  e.,  the  broad 
reflection  of  the  inner  end  of  Poupart's  ligament  to  the  crest  of  the  pubis).  This  space  gives 
passage  to  the  great  vessels  and  is  called  the  lacuna  vasorum;  the  space  beneath  Poupart's  liga- 
ment to  the  outer  side  of  the  iliopectineal  fascia  is  known  as  the  lacuna  musculorum.  The 
femoral  artery  is  situated  in  the  outer  portion  of  the  lacuna  vasorum,  and  the  femoral  vein  is 
placed  immediately  to  the  inner  side  of  the  artery,  but  it  does  not  extend  to  the  concave  margin 
of  Gimbernat's  ligament.  There  is  left  between  the  vein  and  the  margin  of  the  ligament  a 
small  space  which  is  filled  by  connective  tissue  and  frequently  also  by  a  lymphatic  gland  (the 
gland  of  Rosenmilller).  This  space  is  the  femoral  ring  (annulus  femoralis),  the  place  of  exit 
of  femoral  hernia  which  pushes  the  peritoneum  before  it,  passes  beneath  Poupart's  ligament, 
and  appears  beneath  the  skin  at  the  saphenous  opening. 

The  saphenous  opening  (fossa  ovalis)  in  the  fascia  lata,  bounded  externally  by  the  margo 
falciformis  (Fig.  77),  is  closed  by  a  thin  fascia  which  is  called  the  cribriform  fascia.  The  internal 
saphenous  vein,  the  varicose  dilatations  of  which  are  more  or  less  troublesome,  runs  up  the 
inner  side  of  the  thigh  somewhat  posterior  to  the  margin  of  the  sartorius  muscle,  and  passes 
through  the  saphenous  opening  to  empty  into  the  femoral  vein.  The  cribriform  fascia,  or  the 
adjacent  portions  of  the  fascia  lata,  are  perforated  by  the  superficial  epigastric  and  superficial 
circumflex  iliac  vessels  and  also  by  smaller  arterial  branches  on  their  way  to  supply  the  numerous 


158  TOPOGRAPHIC   AND    APPLIED    ANATOMY. 

so-called  inguinal  glands  (lymphoglandulae  subinguinales).  Two  arteries,  the  superficial  and 
deep  external  pudic,  also  pass  inward  with  their  accompanying  veins.  The  lymphatic  glands 
in  this  region  lie  mostly  upon  the  fascia,  but  a  few  of  them  are  situated  beneath  it;  they  collect 
the  lymph  not  only  from  the  lower  extremity,  but  also  from  the  external  genitalia.  This  fact 
explains  the  frequent  extension  of  diseases  of  the  external  genitalia  to  these  lymphatic  glands. 
[The  inguinal  lymphatic  nodes  are  divided  into  a  superficial  and  a  deep  set.  The  latter  are 
grouped  around  the  upper  end  of  the  femoral  vein.  The  superficial  are  subdivided  into  two 
groups:  an  upper  (oblique),  below  and  parallel  with  Poupart's  ligament,  and  a  lower,  vertical, 
near  the  saphenous  opening.  The  outermost  nodes  of  the  superior  group  receive  tributaries 
from  the  buttock  and  lower  part  of  the  back,  the  innermost  from  the  lower  part  of  the  anterior 
belly  wall,  from  the  urethra  and  penis  (in  the  female,  urethra,  vulva,  and  lower  third  of  the 
vagina),  perineum,  scrotum,  lower  and  inner  part  of  the  buttocks,  and  the  integument  around  the 
anus.  The  group  around  the  saphenous  opening  receives  the  superficial  tributaries  from  all  of 
the  lower  extremity  except  a  small  area  in  the  vicinity  of  the  external  saphenous  vein,  which 
drains  into  the  popliteal  nodes,  thence  to  deep  inguinal,  and  thence  to  external  iliac,  etc.,  without 
involving  either  of  the  superficial  groups.  Occasionally,  however,  the  urethra,  penis,  vulva, 
lower  third  of  vagina,  scrotum,  and  perineum  may  communicate  with  the  inferior  group,  and 
the  lymphatics  of  the  uterus,  according  to  Gerrish,  may  communicate  with  the  superior  set. 
The  practical  facts  in  this  connection  are  stated  by  Eisendrath  as  follows :  the  upper  group  drains 
the  anal  canal,  perineum,  lower  portion  of  vagina,  male  and  female  external  genitalia,  and  the 
skin  of  the  lower  portion  of  the  anterior  abdominal  wall  and  the  gluteal  region.  The  lower  set 
receives  lymph  from  the  entire  lower  extremity. — Ed.] 

Muscles. — The  muscles  of  the  hip  are  grouped  about  the  external  and  internal  surfaces 
of  the  pelvis  and  run  to  the  trochanteric  region  of  the  femur.  The  iliopsoas  muscle  consists  of 
the  psoas  major  (arising  from  the  sides  of  the  twelfth  dorsal  and  of  the  four  upper  lumbar  ver- 
tebras), of  the  iliacus  (arising  from  the  inner  surface  of  the  ilium),  and  of  the  inconstant  psoas 
minor;  it  is  inserted  into  the  lesser  trochanter.  Opposing  this  muscle,  we  have  the  large  muscles 
of  the  buttocks  passing  to  the  great  trochanter,  and  also  the  external  rotators  coming  from 
the  true  pelvis.  The  muscles  of  the  buttocks  are  the  gluteus  maximus,  medius,  and  minimus 
(Fig.  78).  The  gluteus  maximus  arises  from  the  posterior  surface  of  the  ilium  behind  the  superior 
curved  line  (linea  glutaea  posterior),  from  the  outer  surface  of  the  sacrum  and  of  the  coccyx, 
and  from  the  great  sacrosciatic  ligament,  and  goes  to  the  fascia  lata  and  to  the  tuberositas, 
glutaea  femoris  (the  rough  line  leading  from  the  great  trochanter  to  the  linea  aspera).  Between 
its  tendon  and  the  great  trochanter  is  situated  the  large  bursa  trochanterica.  The  gluteus  medius 
arises  from  the  ilium  between  the  superior  and  middle  curved  lines  (linea  glutaea  posterior  and 
anterior)  and  runs  to  the  outer  surface  of  the  great  trochanter.  The  gluteus  minimus  arises 
from  the  ilium  between  the  middle  and  inferior  curved  lines  (linea  glutaea  anterior  and  linea 
glutaea  inferior)  and  inserts  into  the  anterior  surface  of  the  great  trochanter.  The  external 
rotators  are  the  pyriformis,  the  obturator  internus,  the  gemelli,  the  obturator  externus,  and  the 
quadratus  femoris.  The  pyriformis,  in  relation  with  the  inferior  margin  of  the  gluteus  medius, 
passes  from  the  anterior  surface  of  the  sacrum  through  the  great  sacrosciatic  foramen  to  the 
trochanteric  fossa  (foramina  supra pyriforme  and  infra pyriforme,  see  page  146).     The  obturator 


Kg-  79- 


Superficial  epigastric  artery 

Poupart's  ligament 
Anterior  crural  nerve 

Deep  epigastric  artery 

M.  iliopsoas 

Femoral  vein 

Femoral  artery 

Cutaneous  branches 

Profunda  femoris  artery 

Internal  saphenous  vein 


M.  sartorius 


M.  vastus  lat.  - 


M.  rectus  femoris 


M.  pectineus 

Obturator  nerve 
""  (anterior  branch) 
--  M.  adductor  longus 


M.  gracilis 


M.  adductor  magnus 


M.  vastus  medialis 

Femoral  artery 

Long  saphenous  nerve 

Femoral  vein  (almost  entirely 
concealed) 

M.  sartorius 
Anterior  wall  of  Hunter's    canal 


Anastomotica  magna  artery 
Tendon  of  adductor  magnus 


External  iliac  artery 
External  iliac  vein 

Poupart's  ligament 

Femoral  vein 

.    Femoral  artery 

Superficial  external  pudic 

artery 

Profunda  femoris  artery 

Fascia  lata 


Lymphatic  gland 


Fig.  80. 


Skin 

Subcutaneous  connective  tissue 
Fascia  lata 


Fig.  81. 


Skin 

Subcutaneous  connect,   tissue 

Aponeurosis 

Musculature 

Transversalis  fascia 

Peritoneum 


Superficial  epigastric  artery 


THE   THIGH.  j^g 


Fig.  79. — The  anterior  femoral  region. 

Fig.  80.— The  exposure  of  the  femoral  artery  before  its  entrance  into  Hunter's  canal. 

Fig.  81.— The  subperitoneal  exposure  of  the  external  iliac  artery.     Below  Poupart's  ligament  the  femoral  vessels 
nave  also  been  exposed. 


interims  takes  origin  from  the  inner  surface  of  the  obturator  membrane  and  from  the  surrounding 
bones;  it  leaves  the  pelvis  through  the  lesser  sacrosciatic  foramen  and  passes  to  the  trochanteric 
fossa,  accompanied  by  the  superior  and  inferior  gemelli  muscles  (arising  from  the  spine  and 
from  the  tuberosity  of  the  ischium  respectively).  The  obturator  externus  runs  from  the  outer 
surface  of  the  obturator  membrane  to  the  trochanteric  fossa.  The  quadratus  jemoris  passes 
from  the  tuberosity  of  the  ischium  to  the  crista  intertrochanterica  (linea  quadrati). 

After  dividing  the  gluteus  maximus  at  right  angles  to  the  course  of  its  muscular  fibers  (Fig. 
78)  the  inferior  gluteal  nerve  is  exposed  as  it  leaves  the  pelvis  through  the  infrapyriform  fora- 
men and  radiates  upward  into  the  substance  of  the  divided  muscle.  The  other  nerves  leaving 
the  pelvis  by  way  of  the  infrapyriform  foramen  to  reach  the  skin  of  the  posterior  surface  of  the 
thigh  are  the  small  sciatic,  the  great  sciatic  (the  portion  which  subsequently  becomes  the  pero- 
neal nerve  frequently  perforating  the  pyriformis  muscle),  and  the  internal  pudic.  The  latter 
nerve  immediately  re-enters  the  pelvis,  however,  through  the  lesser  sacrosciatic  foramen.  The 
branches  of  the  internal  iliac  artery  escaping  from  the  pelvis  below  the  pyriformis  muscle  are 
the  sciatic,  chiefly  supplying  the  gluteus  maximus  and  giving  off  the  comes  nervi  ischiadici,  and 
the  internal  pudic,  which  is  accompanied  by  the  pudic  nerve  and  supplies  the  terminal  portion 
of  the  rectum,  the  perineum,  and  the  external  genitalia.  The  suprapyriform  foramen  is  ex- 
posed by  dividing  the  gluteus  medius  muscle  (Fig.  78).  The  gluteal  artery  leaves  the  pelvis 
through  this  foramen;  it  sends  a  branch  between  the  gluteus  maximus  and  medius  and  gives 
off  another  below  the  gluteus  medius.  This  artery  is  accompanied  by  the  superior  gluteal  nerve, 
which  passes  over  the  superior  margin  of  the  pyriformis  and  supplies  the  gluteus  medius,  the 
gluteus  minimus,  and  the  tensor  fasciae  latae  muscles.  It  should  be  noted  that  one  artery  and 
one  nerve  leave  the  pelvis  above  the  pyriformis  muscle,  and  that  two  arteries  and  four  nerves 
pass  out  below  this  structure. 

THE  THIGH. 

The  Muscles. — The  muscles  of  the  thigh  surround  the  femur  in  such  a  manner  that  only 
the  great  trochanter  above,  the  condyles  below,  are  palpable  beneath  the  skin.  We  differentiate 
the  anterior  group  of  extensors,  the  posterior  group  of  flexors,  and  the  internal  group  of  adduc- 
tors (Figs.  79  and  82).  There  is  also  a  superficial  group  composed  of  the  tensor  jascue  lata, 
passing  from  the  anterior  superior  spine  of  the  ilium  to  the  fascia  lata,  and  of  the  sarlorius,  which 
arises  from  the  anterior  superior  iliac  spine  and  inserts  into  the  tibia  below  the  internal  tuber- 
osity and  as  far  forward  as  the  tibial  tubercle. 

The  quadriceps  extensor  cruris  consists  of  four  parts:  the  rectus,  the  vastus  externus,  the 
vastus  internus,  and  the  crureus.  The  rectus  muscle  arises  by  two  short  tendons  from  the  an- 
terior inferior  iliac  spine  and  from  the  bone  alongside  of  the  acetabulum;  the  vastus  externus 
springs  from  the  great  trochanter,  from  the  outer  lip  of  the  linea  aspera,  and  from  the  external 
intermuscular  septum;   the  vastus  internus  takes  origin  from  the  inner  lip  of  the  linea   aspera 


160  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

and  from  the  internal  intermuscular  septum;  the  crureus  (vastus  intermedius)  arises  from  the 
intertrochanteric  line,  is  covered  by  the  rectus,  and  is  adherent  in  a  varying  degree  to  the  vastus 
externus  and  internus  muscles.  The  quadriceps  surrounds  the  shaft  of  the  femur  with  the  ex- 
ception of  the  linea  aspera  and  of  the  planum  popliteum.  All  four  portions  of  this  muscle  ter- 
minate above  the  knee  in  a  common  tendon  which,  after  enclosing  the  patella,  is  inserted  as  the 
ligamentum  patellae  into  the  tubercle  of  the  tibia. 

The  three  flexor  muscles  are  situated  posteriorly  and  take  origin  from  the  tuberosity  of  the 
ischium.  The  biceps  flexor  cruris,  in  addition  to  its  long  head  which  arises  in  common  with 
the  semitendinosus  from  the  tuberosity  of  the  ischium,  has  a  short  head  from  the  outer  lip  of 
the  linea  aspera;  the  muscle  inserts  into  the  head  of  the  fibula.  The  semitendinosus  muscle  has 
a  long  tendon  which  imbeds  itself  in  a  broad  furrow  upon  the  posterior  surface  of  the  semi- 
membranosus and  inserts  into  the  tibia  behind  the  gracilis  and  sartorius  muscles  with  a  broad 
tendon  extending  as  far  forward  as  the  tibial  crest.  The  semimembranosus  muscle  arises  by  a 
broad  tendon  from  the  ischial  tuberosity  and  is  inserted  into  the  posterior  surface  of  the  internal 
tuberosity  of  the  tibia. 

The  adductors  are  interposed  between  the  extensors  and  flexors  of  the  thigh ;  they  arise  from 
the  pelvis  and  run  to  the  inner  lip  of  the  linea  aspera  and  to  the  internal  epicondyle  of  the  femur. 
The  common  tendon  contains  several  small  orifices  for  the  perforating  arteries,  which  run  from 
the  anterior  to  the  posterior  surfaces  of  the  thigh,  and  also  the  large  slit  (hiatus  adductorius) 
for  the  passage  of  the  femoral  vessels  into  the  popliteal  space.  The  pectineus  muscle  commences 
at  the  crest  of  the  os  pubis,  converges  toward  the  iliopsoas,  and  runs  posteriorly  to  the  linea 
pectinea  femoris.  Since  it  runs  posteriorly  with  the  iliopsoas  muscle,  a  fossa  is  formed  below 
Poupart's  ligament,  covered  by  the  fascia  lata  (fossa  ilio  pectinea),  in  which  the  large  femoral 
vessels  are  situated  (Fig.  79).  It  forms  the  deepest  portion  of  Scarpa's  triangle  (trigonum  femor- 
ale),  which  is  bounded  internally  by  the  inner  margin  of  the  adductor  longus  and  externally  by 
the  inner  margin  of  the  sartorius.  The  adductor  longus  muscle  takes  origin  from  the  pubis 
below  the  pubic  spine  and  is  attached  to  the  inner  lip  of  the  linea  aspera.  The  adductor  brevis 
muscle  passes  from  the  inferior  ramus  of  the  pubis  to  the  upper  third  of  the  inner  lip  of  the  linea 
aspera;  the  gracilis  muscle  runs  from  the  inferior  pubic  ramus  to  the  tibia  below  the  internal 
tuberosity,  extending  as  far  forward  as  the  tibial  tubercle;  the  adductor  magnus  muscle,  situated 
most  posteriorly,  arises  from  the  inferior  ramus  of  the  pubis  and  of  the  ischium  as  well  as  from  the 
ischial  tuberosity  and  is  inserted  along  the  entire  length  of  the  inner  lip  of  the  linea  aspera  and  also 
by  a  strong  tendon  into  the  internal  epicondyle  of  the  femur.  The  hiatus  adductorius  is  situated 
above  this  tendon.  At  the  junction  of  the  middle  and  lower  thirds  of  the  femur  an  aponeurosis  is 
stretched  across  from  the  tendon  of  the  adductor  magnus  to  the  vastus  internus ;  this  aponeurosis 
forms  the  anterior  and  internal  wall  (Fig.  80)  of  a  canal  ending  at  the  hiatus  adductorius,  the 
canalis  adductorius  or  canal  0}  Hunter.  The  posterior  wall  of  this  canal  is  formed  by  the  asso- 
ciated tendons  of  the  adductor  longus  and  magnus  muscles  and  it  is  bounded  externally  by  the 
vastus  internus  and  the  femur.     This  canal  gives  passage  to  the  femoral  artery  and  vein. 

Femoral  Artery. — The  femoral  artery  (Figs.  79-82)  passes  beneath  Poupart's  ligament 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis  and  enters  the 
fossa  iliopectinea.     In  this  situation  the  artery  may  be  compressed  against  the  underlying   ilio- 


Fig.  82. 


M.  rectus  femoris 
Femur 


M.  vastus  medialis  _ 


M.  sartorius 

Long  saphenous  nerve 

Femoral  artery 

Femoral  vein 


Long  saphenous  vein 
V.  saphena  magna 


M.  adductor  magnus 
M.  gracilis 


Skin 

Subcutaneous  connect,  tissue 

Fascia  lata 

M.  vastus  lateralis 


Profunda  femoris  artery 
Great  sciatic  nerve 

M.  biceps  femoris 
(long  head) 


M.  semimembranosus  and 
m.  semitendinosus 


THE   THIGH.  ^i 

Fig.  82. — A  cross-section  above  the  middle  of  the  thigh. 


pectineal  eminence;  care  must  be  taken  to  avoid  pressing  upon  the  vein,  which  is  situated  in- 
ternally. We  differentiate  three  portions  of  the  artery.  The  first  portion  extends  from  Pou- 
part's  ligament  to  the  sartorius  muscle  and  is  situated  in  Scarpa's  triangle.  In  addition  to  the 
superficial  vessels  previously  mentioned  (see  page  121)  the  femoral  artery  gives  off  the  large 
trunk  of  the  profunda  femoris  (Fig.  81).  This  vessel  usually  arises  about  three  centimeters  below 
Poupart's  ligament ;  it  may,  however,  commence  at  a  higher  level,  and  this  point  must  be  borne 
in  mind  in  ligating  the  femoral  artery.  The  two  large  circumflex  arteries  arise  here  as  well  as  the. 
three  perforating  arteries  for  the  flexor  surface.  From  the  iliopectineal  fossa  the  artery  runs 
in  the  groove  between  the  vastus  internus  and  the  adductors,  covered  only  by  the  fascia  lata, 
and  then  passes  beneath  the  sartorius  muscle.  It  consequently  leaves  Scarpa's  triangle  and 
enters  upon  the  second  portion  of  its  course,  which  is  situated  below  the  sartorius  muscle.  In 
this  situation  it  may  be  readily  exposed  by  the  aid  of  a  line  drawn  from  the  middle  of  Poupart's 
ligament  to  the  inner  condyle  of  the  femur  and  by  displacing  the  sartorius  internally.  The 
third  portion  of  the  vessel  is  found  in  Hunter's  canal  (canalis  adductorius,  see  page  160).  Be- 
fore entering  the  canal,  or  in  the  canal  itself,  the  artery  gives  off  the  anastomotica  magna,  which 
runs  to  the  knee-joint. 

Femoral  Vein. — The  femoral  vein  (Fig.  79)  is  to  the  inner  side  of  the  artery  above,  but 
gradually  passes  behind  it,  so  that  at  the  entrance  to  Hunter's  canal  the  vein  is  almost  entirely 
concealed  by  the  artery  (Fig.  80).  The  nearer  we  approach  to  the  knee,  the  firmer  becomes 
the  connective  tissue  between  the  artery  and  the  vein,  for  which  reason  the  ligation  of  the  artery 
in  this  situation  is  more  difficult  on  account  of  the  necessary  isolation  of  the  vein. 

Anterior  Crural  Nerve. — The  anterior  crural  nerve  (Fig.  79),  the  motor  nerve  for  the  quad- 
riceps and  the  sartorius  muscles,  passes  to  the  thigh  through  the  lacuna  musculorum  (see  page 
157  and  Fig.  76)  to  the  outer  side  of  the  femoral  artery  and  separated  from  it  by  the  iliopecti- 
neal fascia.  It  is  scarcely  endangered  by  the  ligation  of  the  artery,  and  divides  just  below  Pou- 
part's ligament  into  cutaneous  and  muscular  branches.  The  longest  branch  is  the  cutaneous 
nerve,  designated  as  the  long  saphenous  (Figs.  80  and  82),  which  accompanies  the  femoral  artery 
to  Hunter's  canal ;  the  nerve  then  passes  through  the  anterior  wall  of  the  canal,  runs  beneath  the 
sartorius  muscle,  perforates  the  fascia  lata  behind  the  insertion  of  the  sartorius,  and  accompanies 
the  long  saphenous  vein  to  the  internal  malleolus. 

Sciatic  Nerve. — The  sciatic  nerve,  the  motor  nerve  of  the  flexors,  and  often  made  familiar 
to  the  laity  by  sciatica,  leaves  the  pelvis  through  the  infrapyriform  foramen  (see  page  146  and 
Figs.  78  and  82);  it  lies  at  first  upon  the  obturator  internus  and  the  two  gemelli  muscles  be- 
neath the  gluteus  maximus,  and  then  upon  the  quadratus  femoris  between  the  great  trochanter 
and  the  tuberosity  of  the  ischium.  It  becomes  superficial  at  the  lower  border  of  the  gluteus 
maximus  muscle  and  for  a  short  distance  is  covered  only  by  the  skin  and  fascia.  In  this  situa- 
tion the  nerve  is  accessible  to  electric  and  surgical  treatment.  In  order  to  expose  the  nerve  the 
patient  is  placed  upon  the  abdomen  and  a  line  is  drawn  from  the  great  trochanter  to  the  tuber- 
osity of  the  ischium;  an  incision  is  now  made  parallel  to  the  inferior  margin  of  the  gluteus  maxi- 
mus at  the  junction  of  the  inner  and  middle  thirds  of  this  line.     It  must  be  remembered  that 


1 62  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

the  gluteofemoral  crease  does  not  correspond  with  the  inferior  margin  of  the  gluteus  maximus, 
but  that  it  is  situated  from  two  to  three  fmgerbreadths  above  this  margin.  In  its  further  course 
the  sciatic  nerve  passes  beneath  the  muscles  arising  from  the  tuberosity  of  the  ischium,  disappear- 
ing beneath  the  biceps,  and  runs  downward  in  the  middle  of  the  posterior  surface  of  the  thigh, 
covered  by  the  long  head  of  the  biceps,  to  reach  the  popliteal  space.  Anteriorly  the  nerve  rests 
upon  the  adductor  magnus  muscle.  It  is  surrounded  by  very  loose  connective  tissue  in  which 
gravitating  abscesses  leaving  the  pelvis  through  the  sciatic  foramina  may  extend  downward 
along  the  nerve  into  the  popliteal  space.  The  nerve  may  divide  high  up  into  its  two  terminal 
branches,  the  internal  and  the  external  popliteal  nerves;  the  point  of  division  is  usually  situated 
just  above  the  popliteal  fossa  (Fig.  83).  The  nerve  supplies  the  long  head  of  the  biceps,  the 
semimembranosus,  and  the  semitendinosus  from  the  portion  which  subsequently  becomes  the 
internal  popliteal  nerve,  and  the  short  head  of  the  biceps  from  the  portion  which  goes  to  form 
the  external  popliteal  nerve.  The  sciatic  nerve  also  gives  filaments  to  the  adductor  magnus 
muscle. 

Obturator  Nerve. — The  obturator  nerve  (Figs.  71  and  73),  the  motor  nerve  of  the  adductors 
and  the  last  branch  of  the  lumbar  plexus,  runs  into  the  true  pelvis  to  the  inner  side  of  the  psoas 
muscle,  and,  accompanied  by  the  obturator  artery,  to  the  obturator  canal,  and  divides,  after  its 
exit  from  the  canal,  into  an  anterior  and  a  posterior  branch.  The  anterior  branch  lies  between 
the  adductor  brevis  upon  one  side  and  the  pectineus  and  the  adductor  longus  upon  the  other; 
it  supplies  these  muscles  and  the  gracilis  and  ends  in  an  unimportant  cutaneous  branch  upon  the 
inner  side  of  the  thigh  (Fig.  79).  The  posterior  branch  lies  beneath  the  adductor  brevis  and 
upon  the  adductor  magnus  and  supplies  the  latter  muscle. 

THE  REGION  OF  THE  KNEE. 

In  the  region  of  the  knee  may  be  easily  seen  and  felt  the  movable  patella,  imbedded  in  the 
tendon  of  the  quadriceps  and  covered  only  by  the  skin  and  bursas  (see  page  165),  and  the  liga- 
tnentum  patella;,  which  passes  from  the  apex  of  the  bone  to  the  tubercle  of  the  tibia.  To  either 
side  may  be  felt  the  condyles  and  the  epicondyles  of  the  femur.  When  the  knee  is  flexed,  the 
patella  descends  so  that  the  upper  portion  of  the  intercondyloid  fossa  of  the  femur  (the  trochlea) 
is  exposed  to  palpation.  To  the  outer  side  of  the  extended  knee  a  strong  band  may  be  distinctly 
felt  passing  upward  from  the  external  epicondyle;  this  structure  is  the  terminal  portion  of  the 
iliotibial  band  of  the  fascia  lata.  To  either  side  of  the  patellar  tendon  may  be  felt  the  articular 
space  between  the  tibia  and  the  femur,  and,  upon  the  outer  side  of  the  joint,  the  head  of  the 
fibula  and  the  strong  tendon  of  the  biceps  which  passes  upward  from  this  structure.  [On  either 
side  of  the  patella  and  above  it  are  depressions;  these,  with  the  depressions  on  either  side  of  the 
patellar  ligament,  disappear  when  there  is  fluid  in  the  joint  cavity.  When  fluid  is  present,  the 
patella  "floats";  which  means  that  by  pressure  backward  the  patella  may  be  forced  in  contact 
with  the  femur,  but  when  the  pressure  is  released  it  rebounds. — Ed.]  When  the  knee  is  flexed,  the 
biceps  tendon  may  be  followed  upward  upon  the  posterior  surface  of  the  thigh.  It  forms  the 
outer  boundary  of  the  upper  portion  of  the  popliteal  fossa,  the  inner  boundary  being  furnished 
by  the  tendons  of  the  semitendinosus,  semimembranosus,  and  gracilis.  The  lower  portion  of 
the  diamond-shaped  popliteal  fossa  is  bounded  by  the  origins  of  the  gastrocnemius  muscle. 


, 


Fig.  8,. 


M,  gracilis 
M.  semimembranosus 


M.  biceps  femoris  (short  head) 

M.  biceps  femoris  (long  head) 
Internal  popliteal  nerve 

External  popliteal  nerve 
(peroneal  nerve) 

Superior  external  articular  artery 

Inferior  external  articular  artery 

Communicans  peronei 

M.  gastrocnemius  (,outer  head) 

Communicans  poplitei 

Short  saphenous  vein 


Fig.  84. 


Suprapatellar  bursa  - 
Tendon  of  quadriceps  - 
Synovial  membrane  of  _ 
knee-joint 

Prepatellar  bursa  -. 


Femur 


Deep  infrapatellar  bursa 
Lig.  patellae 

Subcutaneous  bursa  over 
the  tubercle  of  the  tibia 


Outer  head  of  gastrocnemius 


Bursa  between  semimembranosis 
and  outer  head  of  gastrocnemius 
M.  semimembranosus 


THE  REGION  OF  THE  KNEE.  163 


Fig.  83. — The  popliteal  space. 


Fig.  84.— The  knee-joint  after  the  injection  of  a  blue  mass  into  the  articular  cavity;  the  bursas  communicating  with 
the  joint  are  also  filled  with  the  blue  injection.  The  non-communicating  bursas  have  been  injected  with  a  red  mass. 
(From  a  Berlin  model.) 


The  superficial  structures  of  the  popliteal  space  are  the  short  saphenous  vein  and  nerve 
(Fig.  83).  The  short  saphenous  vein  lies  upon  the  deep  fascia.  It  arises  behind  the  external 
malleolus,  runs  upward  upon  the  muscles  of  the  calf  in  the  furrow  between  the  two  heads  of  the 
gastrocnemius,  perforates  the  deep  fascia  in  the  popliteal  space,  and  empties  into  the  popliteal 
vein.  It  usually  gives  off  a  branch  which  runs  to  a  higher  level  and  empties  into  the  vena  pro- 
funda femoris.  To  the  outer  side  of  the  vein  the  short  saphenous  nerve  runs  downward  as  far 
as  the  external  border  of  the  foot.  This  nerve  arises  upon  or  beneath  the  deep  fascia  in  the 
popliteal  space  or  lower  down  by  the  union  of  the  communicans  poplitei  (n.cutaneus  surae  medialis) 
from  the  internal  popliteal  nerve,  with  the  communicans  peronei  (n.  cutaneus  surae  lateralis), 
from  the  peroneal  nerve.  To  the  inner  side  of  the  knee  is  the  internal  (or  long)  saphenous  vein, 
and  somewhat  posterior  to  this  structure  the  long  saphenous  nerve  makes  its  appearance  be- 
neath the  tendon  of  the  sartorius  muscle  (see  page  161).  In  the  median  line  of  the  popliteal 
space  the  internal  popliteal  nerve  may  be  felt,  and  even  seen  in  spare  individuals,  when  the  knee 
is  extended;  it  is  the  motor  nerve  of  the  flexor  surface  and  gives  off  branches  to  the  heads  of  the 
gastrocnemius  muscle  in  this  situation.  Somewhat  deeper  and  closely  associated  with  the  nerve 
upon  its  inner  side  is  the  popliteal  vein,  and  still  deeper  and  more  internal  is  the  popliteal  artery. 
The  popliteal  artery  makes  its  appearance  at  the  opening  in  the  adductor  magnus  and  lies  first 
upon  the  posterior  surface  of  the  vastus  internus  and  then  upon  the  planum  popliteum,  though 
it  is  separated  from  this  bony  surface  by  a  small  quantity  of  fat;  lower  down  the  vessel  is  inti- 
mately related  with  the  capsular  ligament  of  the  joint,  so  that  it  will  be  readily  understood  that 
the  artery  and  its  accompanying  vein  must  suffer  compression  in  posterior  dislocations  at  the 
knee,  and  that  this  relation  must  always  be  borne  in  mind  in  resections  of  the  articulation.  It 
is  also  clear  that  in  supracondyloid  fractures  of  the  lower  end  of  the  femur  in  which  the  lower 
fragment  is  tilted  backward  by  the  gastrocnemius  muscle  disagreeable  symptoms  will  be  pro- 
duced by  the  laceration  of  the  popliteal  vessels  and  of  the  internal  popliteal  nerve.  The  artery 
finally  runs  upon  the  popliteus  muscle,  at  the  inferior  margin  of  which  it  divides  into  its  terminal 
branches,  the  anterior  and  posterior  tibial  arteries.  In  addition  to  the  numerous  branches  to 
the  muscles  in  this  region,  of  which  the  large  sural  arteries  to  the  heads  of  the  gastrocnemius 
should  be  particularly  emphasized,  the  popliteal  gives  off  five  articular  arteries,  which  vary  in 
size  and  aid  in  the  formation  of  the  rete  articulare.  There  are  two  superior  and  two  inferior 
articular  arteries  (an  external  and  an  internal  of  each),  and  an  azygos  articular  (a.  articularis 
genu  media)  which  passes  into  the  interior  of  the  joint. 

The  peroneal  nerve  (external  popliteal)  (Fig.  83)  follows  the  inner  border  of  the  biceps 
muscle  and  graduallv  becomes  more  distant  from  the  internal  popliteal  nerve;  at  the  head  of 
the  fibula  it  enters  the  peroneus  longus  muscle  and  immediately  divides  into  its  two  main  branches, 
the  musculocutaneous  and  the  anterior  tibial  nerves. 

Knee-joint.— The  study  of  the  knee-joint  (Fig.  84)  should  be  preceded  by  a  review  of  the 
following  parts:   At  the  lower  end  of  the  femur,  the  condyles,  the  epicondyles,  the  fossa  inter- 


164  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

condylea,  the  linea  intercondylea,  and  the  facies  patellaris;  at  the  upper  end  of  the  tibia,  the 
tuberosities  with  their  articular  surfaces,  the  eminentia  intercondylea,  the  tuberculum  intercon- 
dyleum  anterius  and  posterius,  and  the  fossa  intercondylea  anterior  and  posterior.  The  head 
of  the  fibula  is  connected  to  the  tibia  by  an  articulation  which  does  not  communicate  with  the 
knee-joint.  The  posterior  surface  of  the  patella  is  covered  by  hyaline  cartilage  and  forms  the 
immediate  anterior  boundary  of  the  articular  cavity;  during  flexion  and  extension  of  the  joint 
it  slides  up  and  down  upon  the  facies  patellaris  of  the  femur.  The  incongruity  of  the  articular 
surfaces  of  the  tibia  and  of  the  femur  is  partly  compensated  for  by  the  interposition  of  the  in- 
ternal and  external  semilunar  cartilages  (meniscus  lateralis  and  medialis).  The  external  meniscus 
is  the  more  sharply  curved  and  its  ends  are  attached  immediately  in  front  of  and  behind  the 
spine  of  the  tibia  (eminentia  intercondylea  tibiae).  The  internal  meniscus  is  more  semilunar  in 
shape ;  it  commences  in  front  at  the  margin  of  the  articular  surface  of  the  tibia  and  ends  behind 
at  the  posterior  intercondyloid  fossa. 

The  capsular  ligament  is  in  very  intimate  relation  with  muscle-insertions  which  help  to 
strengthen  it.  Anteriorly  the  tendon  of  the  quadriceps  encloses  the  patella  and  ends  in  the 
patellar  ligament  running  to  the  tubercle  of  the  tibia.  Posteriorly  are  the  popliteus,  the  origins 
of  the  gastrocnemius,  and  the  insertion  of  the  semimembranosus,  externally  the  biceps  runs  to 
the  head  of  the  fibula,  and  internally  are  the  three  tendons  of  the  sartorius,  semitendinosus,  and 
gracilis,  forming  the  "pes  anserinus."  The  capsular  ligament  passes  from  the  posterior  surface 
of  the  tendon  of  the  quadriceps  to  the  anterior  surface  of  the  end  of  the  femur  somewhat  above 
its  cartilaginous  surface  and  excludes  the  epicondyles  from  the  articular  cavity.  Posteriorly  it 
is  attached  to  the  intercondyloid  line.  At  the  tibia  the  capsular  ligament  runs  from  the  edge  of 
the  cartilaginous  surface  to  the  outer  borders  of  the  menisci,  and  to  the  inferior  margin  of  the 
patella.  At  the  upper  and  anterior  portion  of  the  articular  cavity  the  large  suprapatellar  bursa 
is  situated  between  the  femur  and  the  quadriceps  tendon  and  communicates  directly  with  the 
joint  (Fig.  84).  This  bursa  extends  upward  a  distance  of  four  to  eight  centimeters  above  the 
upper  margin  of  the  patella  with  the  leg  in  the  extended  position. 

The  ligaments  consist  of  internal,  lateral,  and  posterior  bands  of  connective  tissue.  The 
internal  ligaments  are  the  ligamenta  cruciata,  and  they  check  excessive  pronation.  The  anterior 
crucial  ligament  passes  from  the  inner  surface  of  the  external  condyle  of  the  femur  to  the  anterior 
intercondyloid  fossa  of  the  tibia;  the  posterior  crucial  ligament  runs  from  the  outer  surface  of 
the  internal  condyle  to  the  posterior  intercondyloid  fossa.  Both  ligaments  are  united  to  each 
other  by  connective  tissue,  project  into  the  interior  of  the  joint  from  the  posterior  portion  of  the 
capsular  ligament,  and  are  incompletely  covered  by  the  synovial  membrane.  The  lateral  liga- 
ments are  the  ligamentum  collaterale  fibulare  (the  long  external  lateral  ligament),  which  runs 
from  the  external  condyle  of  the  femur  to  the  head  of  the  fibula  as  a  comparatively  independent 
structure,  and  the  ligamentum  collaterale  tibiale  (the  internal  lateral  ligament),  a  broad  fibrous 
radiation  in  the  capsular  ligament  extending  from  the  internal  condyle  of  the  femur  to  the  margin 
of  the  cartilaginous  surface  of  the  tibia.  Posteriorly  there  are  two  ligaments:  (1)  The  liga- 
mentum popliteum  obliquum,  running  from  the  external  condyle  of  the  femur  obliquely  down- 
ward and  inward,  where  it  becomes  adherent  to  the  tendon  of  insertion  of  the  semimembranosus 
muscle;    (2)  the  ligamentum  popliteum  arcuatum,  a  curved  fibrous  band  radiating  from  the  ex- 


Fig.  8}. 


Anterior  tibial  artery 
Anterior  tibial  nerve 


M.  extensor  digit,  longus. 


Musculocutaneous  nerve. 


M.  extensor  proprius  hallucis 
M.  peronaeus  longus. 


External  malleolus- 

Short  saphenous  nerve- 
External  branch,  of  musculocn-. 
taneous  nerve 
M.  peronaeus  tertius 

M.  extensor  digitorum  brevis. 


M.  tibialis  ant. 


Internal  malleolus 


Internal  branch    of  musculo- 
cutaneous nerve 

Dorsalis  pedis  artery 


Anterior  tibial  nerve 


First    dorsal    interos- 
seous artery 


Fig.  86. 


M.  tibialis  anterior 


Tibia 

Anterior  tibial  artery 

Interosseous  membrane 

M.  tibialis  posterior 

Posterior  tibial  artery 
Posterior  tibial  nerve 
Long  saphenous  vein 

M.  soleus 
M.  plantaris 

X.  gastrocnemius 
(inner  head) 


-  Skin. 

Superficial  fascia 

M.  extensor  longus  digitorum 

Deep  fascia 

—  M.  peronaeus  longus 

---  Anterior  tibial  nerve 


—  Fibula 


Peroneal  artery 

M.   flexor  longus  hallucis 

M.  flexor  longus  digitorum 


-  M.  gastrocnemius  (outer  head) 


Short  saphenous  nerve 


Short  saphenous  vein 


THE  LEG. 


165 


Fig.  85.— The  nerves  and  vessels  upon  the  anterior  aspect  of  the  leg  and  foot. 
Fig.  86. — A  cross-section  through  the  upper  half  of  the  leg. 


ternal  condyle  of  the  femur  upward  and  inward  in  the  capsular  ligament.  [The  ligamentum 
popliteum  obliquum  (the  ligamentum  posticum  Winslowii)  and  the  ligamentum  popliteum  arcua- 
tum  are  usually  regarded  as  reinforcements  of  the  posterior  ligament  which  is  attached  to  the 
femur  above  and  the  tibia  below. — Ed.] 

No  joint  possesses  so  many  bursas  as  the  knee-joint,  and  diseases  of  the  bursas  are  conse- 
quently more  frequent  here  than  in  any  other  situation.  The  bursas  communicating  with  the 
articular  cavity  (blue  in  Fig.  84)  are:  (1)  The  bursa  suprapatellaris.  (2)  The  bursa  between 
the  semimembranosus  and  inner  head  of  the  gastrocnemius  muscles.  In  effusions  into  the 
knee-joint  this  important  bursa  is  frequently  demonstrable  as  a  fluctuating  tumor  upon  the 
posterior  and  inner  aspect  of  the  knee.  (3)  The  bursa  0}  the  popliteus  muscle;  this  may  extend 
outward  and  communicate  with  the  superior  tibiofibular  articulation. 

The  bursas  not  communicating  with  the  articular  cavity  (red  in  Fig.  84)  are:  (1)  The  pre- 
patellar bursas,  of  which  three  may  sometimes  be  distinctly  differentiated  (bursas  subcutanea, 
subfascialis,  and  subtendinea) ;  as  a  rule,  they  communicate  with  each  other  more  or  less.  They 
frequently  become  inflamed,  and  such  a  condition  should  not  be  confounded  with  arthritis.  (2) 
The  deep  infrapatellar  bursa,  between  the  ligamentum  patellae  and  the  tibia.  (3)  The  sub- 
cutaneous bursa  over  the  tubercle  of  the  tibia.  (4)  The  bursa  anserina,  between  the  tendons  of 
the  sartorius,  semitendinosus,  and  gracilis  muscles  and  the  tibia.  The  sartorius  muscle  fre- 
quently possesses  an  individual  bursa  which  does  not  communicate  with  the  bursa  anserina. 


THE   LEG. 

The  muscles  of  the  leg  are  so  arranged  that  the  only  portions  of  the  bones  which  may  be 
distinctly  felt  are  the  inner  surface,  the  crest,  and  the  internal  malleolus  of  the  tibia,  and  the 
head  and  external  malleolus  of  the  fibula.  Owing  to  the  subcutaneous  position  of  the  internal 
surface  of  the  tibia,  fractures  of  the  bone  in  this  situation  are  frequently  made  compound  by 
concomitant  injury  of  the  integument.  The  extensor  muscles  are  situated  anteriorly  to  the 
outer  side  of  the  tibial  crest  between  the  tibia  and  the  fibula.  Posteriorly  the  curve  of  the  calf 
is  produced  by  the  triceps  sura  muscle,  the  tendon  of  which  (tendo  Achillis)  may  be  distinctly 
felt  in  the  lower  part  of  the  leg.  The  entire  musculature  may  be  subdivided  into  three  groups: 
anteriorly  upon  the  interosseous  membrane  and  between  the  tibia  and  the  fibula  are  the  exten- 
sors; externally,  the  fibula  is  surrounded  by  the  fibular  group;  posteriorly  is  the  flexor  group, 
which  may  be  further  differentiated  into  a  superficial  and  a  deep  layer.  The  anterior  intermus- 
cular septum,  passing  from  the  deep  fascia  to  the  fibula,  separates  the  extensors  from  the  fibular 
group  of  the  peronei  muscles;  the  posterior  intermuscular  septum  passes  from  the  deep  fascia 
to  the  fibula,  in  a  similar  manner,  and  divides  the  peroneal  muscles  from  the  flexor  group.  On 
the  posterior  aspect  of  the  leg  the  deep  layer  of  the  crural  fascia  is  inserted  between  the  super- 
ficial and  the  deep  group  of  the  flexors. 

I.  Extensor  Muscles.— (1)  The  tibialis  anticus  takes  origin  from  the  outer  surface  of   the 


1 66  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

tibia,  from  the  interosseous  membrane,  and  from  the  deep  fascia,  and  runs  to  the  inner  margin 
of  the  sole,  where  it  is  inserted  upon  the  plantar  surfaces  of  the  internal  cuneiform  and  of  the 
first  metatarsal  bones.  (2)  The  extensor  longus  digitorum  arises  from  the  external  tuberosity 
of  the  tibia,  from  the  interosseous  membrane,  from  the  fibula,  and  from  the  deep  fascia,  and 
inserts  by  four  tendons  into  the  four  outer  toes ;  a  fifth  tendon  runs  to  the  base  of  the  fifth  meta- 
tarsal bone  at  the  outer  border  of  the  foot  (M.  peroneus  tertius).  (3)  The  extensor  longus 
hallucis  arises  at  a  lower  level  from  the  interosseous  membrane  between  the  two  former  muscles 
and  runs  to  the  second  phalanx  of  the  great  toe. 

Each  of  the  three  muscles  possesses  an  individual  synovial  sheath  in  the  anterior  annular 
ligament  at  the  ankle. 

II.  Fibular  Muscles. — (1)  The  peroneus  longus.  The  anterior  portion  of  this  muscle  arises 
from  the  external  tuberosity  of  the  tibia,  from  the  head  of  the  fibula,  from  the  anterior  intermus- 
cular septum,  and  from  the  upper  third  of  the  anterior  margin  of  the  fibula;  the  posterior  por- 
tion arises  from  the  fibula  between  the  head  and  the  lower  third  of  the  bone.  The  tendon  runs 
behind  the  external  malleolus,  through  the  groove  of  the  cuboid  bone,  and  passes  obliquely 
across  the  sole  of  the  foot  to  the  base  of  the  first  metatarsal  bone.  (2)  The  peroneus  brevis, 
which  is  covered  by  the  preceding  muscle,  takes  origin  from  the  lower  two-thirds  of  the  fibula  as 
far  down  as  the  external  malleolus.  The  tendon  crosses  that  of  the  peroneus  longus  and  inserts 
into  the  tuberosity  of  the  fifth  metatarsal  bone.  The  tendons  of  both  peroneal  muscles  pass 
through  a  common  compartment  behind  the  external  malleolus  (Fig.  88),  in  which  situation  they 
are  firmly  held  by  two  processes  of  the  crural  fascia  designated  as  retinacula. 

Ill  (a)  Superficial  Flexors  (the  muscles  of  the  calf). — (1)  The  gastrocnemius  arises  by  two 
heads  from  the  bone  above  the  femoral  condyles;  in  the  middle  of  the  leg  the  muscle  becomes 
continuous  with  the  tendo  calcaneus  (Achillis),  which  inserts  into  the  tuberosity  of  the  os  calcis. 
(2)  The  soleus,  beneath  the  preceding  muscle,  arises  from  the  head  and  upper  third  of  the  fibula 
and  from  the  oblique  line  of  the  tibia  and  runs  downward  into  the  tendo  Achillis.  (3)  The 
plantaris,  like  its  analogue  in  the  upper  extremity,  the  palmaris  longus,  is  an  inconstant  muscle. 
It  arises  from  the  external  condyle  of  the  femur  above  the  outer  head  of  the  gastrocnemius  and 
its  tendon  usually  runs  into  the  tendo  Achillis. 

Ill  (b)  Deep  Group  0}  Flexors.— (1)  The  popliteus  runs  from  the  external  condyle  of  the 
femur  and  the  capsular  ligament  of  the  knee-joint  to  the  posterior  surface  of  the  tibia  as  far  down 
as  the  oblique  line.  (2)  The  flexor  longus  digitorum  springs  from  the  posterior  surface  of  the 
tibia.  Its  tendon  crosses  to  the  outer  side  of  the  tibialis  posticus,  enters  the  sole  of  the  foot, 
passes  beneath  and  is  adherent  to  the  tendon  of  the  flexor  longus  hallucis,  and  divides  into  four 
tendons  for  the  four  lesser  toes.  These  tendons  are  inserted  in  a  similar  manner  to  those  of  the 
flexor  profundus  digitorum  in  the  hand.  (3)  The  tibialis  posticus  arises  from  the  interosseous 
membrane  and  the  adjacent  portions  of  the  tibia  and  fibula  in  the  upper  portion  of  the  leg  be- 
tween the  flexor  longus  digitorum  and  the  flexor  longus  hallucis.  Its  tendon,  with  that  of  the 
flexor  longus  digitorum,  passes  behind  the  internal  malleolus  to  the  inner  aspect  of  the  sole  of  the 
foot,  where  it  is  inserted  into  the  internal  cuneiform  and  scaphoid  bones.  (4)  The  flexor  longus 
hallucis  takes  origin  from  the  posterior  surface  of  the  lower  two-thirds  of  the  fibula  and  from  the 
posterior  intermuscular  septum.     Its  tendon  runs  in  the  posterior  sulcus  of  the  astragalus  and 


Fig.  87. 


Tendo  Achillis 


Tuberosity  of  os  calcis 


M.  flexor  brevis  digitorum  — 


M.  abductor  minimi  digiti 

External  plantar  artery 

Superficial  branch  of  external  plantar 
nerve 

Deep  branch   of  external  plantar 
nerve 


Tendons  of  flexor  longus  digi- 
torum 

Tendons  of  flexor  brevis 
digitorum 


Posterior  tibial  nerve 
Posterior  tibial  artery 
M.  tibialis  posticus 

M.  flexor  longus  digitorum 


-External  plantar  nerve 
Internal  plantar  nerve 

-M.  flexor  accessorius 
Internal  plantar  artery 

M.  flexor  longus  hallucis 
Plantar  arch 

M.  adductor  hallucis 
Plantar  digital  artery 


THE   LEG.  j5- 

Fig.  87-The  P^tor  wpect  of  the  foot.     The  flexor  brevis  digitorum  muscle  has  been  divided  and  portions  have  been 
cut  out  of  the  flexor  longus  digitorum,  adductor  hallucis,  and  flexor  brevis  hallucis  muscles. 


behind  the  sustentaculum  tali  of  the  os  calcis  to  the  sole  of  the  foot,  crosses  the  tendon  of  the 
flexor  longus  digitorum,  and  is  attached  to  the  second  phalanx  of  the  great  toe.  Between  the 
internal  malleolus  and  the  tuber  calcanei  each  of  the  tendons  of  the  flexor  longus  digitorum, 
tibialis  posticus,  and  flexor  longus  hallucis  possesses  an  individual  synovial  sheath  which  is 
bridged  over  by  the  internal  annular  ligament  (ligamentum  laciniatum). 

Anterior  Tibial  Artery.— After  the  popliteal  artery  divides  into  its  two  terminal  branches 
at  the  upper  margin  of  the  soleus  muscle,  the  anterior  tibial  artery  (Fig.  85)  gives  off  a  small 
posterior  recurrent  branch  and  passes  anteriorly  above  the  upper  margin  of  the  interosseous 
membrane.  The  vessel  runs  downward  upon  the  anterior  surface  of  the  interosseous  mem- 
brane, being  situated  at  first  between  the  tibialis  anticus  and  extensor  longus  digitorum  muscles, 
and  then  between  the  former  and  the  extensor  longus  hallucis.  Above  the  malleolar  region  the 
artery  lies  directly  upon  the  external  surface  of  the  tibia;  it  then  passes  beneath  the  anterior  an- 
nular ligament  and  runs  forward  upon  the  foot  as  the  dorsalis  pedis.  During  life  the  course  of 
the  artery  is  indicated  by  a  line  drawn  from  a  point  midway  between  the  tubercle  of  the  tibia  and 
the  head  of  the  fibula  to  a  point  upon  the  anterior  surface  of  the  ankle  midway  between  the  two 
malleoli.  In  addition  to  muscular  branches,  the  vessel  gives  off  the  anterior  tibial  artery  above, 
which  runs  upward  to  the  anastomosis  about  the  knee,  and  the  external  and  the  internal  malle- 
olar arteries  below.  None  of  the  branches  are  of  great  importance  from  a  practical  standpoint. 
The  artery  is  accompanied  by  the  anterior  tibial  nerve  (Fig.  85).  This  nerve  pierces  the  origin 
of  the  extensor  longus  digitorum  and  runs  at  first  to  the  outer  side  of  the  artery  and  then  on  top 
of  it  to  the  dorsum  of  the  foot.  It  is  the  motor  nerve  for  the  three  extensor  muscles  and  for 
the  extensor  brevis  digitorum  upon  the  dorsum  of  the  foot.  The  musculocutaneous  nerve  is 
more  superficial  than  the  preceding;  it  passes  between  the  peroneus  longus  and  brevis  muscles, 
supplying  both,  pierces  the  deep  fascia  at  the  junction  of  the  inferior  and  middle  thirds  of  the 
leg,  and  divides,  before  reaching  the  foot,  into  an  external  and  an  internal  branch  (N.  cutaneus 
dor  si  pedis  medial  is  and  intermedius).  In  paralysis  of  the  peroneal  nerve  the  patient  stumbles 
over  his  own  toes  and  loses  sensation  over  almost  all  of  the  dorsum  of  the  foot. 

Posterior  Tibial  Artery. — The  posterior  tibial  artery  (Fig.  86)  runs  between  the  soleus 
and  tibialis  posticus,  beneath  the  flexor  longus  hallucis,  and  then  between  the  flexor  longus 
digitorum  and  the  flexor  longus  hallucis.  It  is  superficial  and  easily  accessible  between  the 
tendo  Achillis  and  the  internal  malleolus.  In  this  situation  it  is  placed  to  the  inner  side  of  the 
posterior  tibial  nerve  and  may  be  readily  ligated.  In  tenotomy  of  the  tendo  Achillis  the  artery 
can  scarcely  be  injured  if  ordinary  care  is  observed.  Behind  the  internal  malleolus  the  vessel 
divides  into  its  terminal  branches — the  external  and  internal  plantar  arteries.  In  the  ligation  of 
the  artery-  behind  the  internal  malleolus  particular  care  must  be  taken  to  avoid  opening  the 
synovial  sheath  of  the  tibialis  posticus,  which  lies  immediately  to  the  inner  side  of  the  vessel 
(Fig.  87).  The  chief  branch  of  the  posterior  tibial,  the  peroneal  artery  (Fig.  86),  arises  high  up, 
runs  downward  behind  the  fibula  covered  by  the  flexor  longus  hallucis  muscle,  and  ends  at  the 
outer  side  of  the  os  calcis  with  branches  to  the  rete  calcanei.     The  posterior  tibial  nerve,  the 


1 68  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

nerve  for  all  of  the  flexor  muscles,  supplies  the  heads  of  the  gastrocnemius  and  also  the  soleus 
in  the  popliteal  space  (Fig.  83)  and  runs  downward  to  the  outer  side  of  the  posterior  tibial  artery 
beneath  the  deep  layer  of  the  crural  fascia.  At  the  internal  malleolus  (Fig.  87)  the  nerve  is 
deeper  than  the  artery  and  closer  to  the  tendo  Achillis.  Before  entering  the  sole  of  the  foot  it 
divides  into  the  internal  and  external  plantar  nerves. 


THE  FOOT. 

Upon  the  dorsal  surface  of  the  foot  may  be  seen  tne  subcutaneous  venous  plexus,  giving 
origin  to  the  short  saphenous  vein  (accompanied  by  the  short  saphenous  nerve)  behind  the  ex- 
ternal malleolus,  and  to  the  long  saphenous  vein  (accompanied  by  the  terminal  ramifications  of 
the  long  saphenous  nerve)  in  front  of  the  internal  malleolus.  These  structures  are  situated  in  a 
loose  connective  tissue,  the  character  of  which  favors  the  occurrence  of  edema.  If  the  foot  is 
strongly  flexed  dorsally,  the  tendon  of  the  extensor  longus  hallucis,  running  to  the  great  toe,  springs 
into  prominence.  To  the  inner  side  of  this  structure  may  be  felt  the  strong  tendon  0}  the  tibialis 
anticus,  on  its  way  to  the  inner  margin  of  the  sole,  the  tendons  0}  the  extensor  longus  digitorum  are 
also  made  prominent  (Fig.  85).  In  dorsal  flexion  the  tense  extensor  brevis  digitorum  is  also  pal- 
pable. In  the  middle  of  the  dorsum  of  the  foot  to  the  outer  side  of  the  tendon  of  the  extensor 
longus  hallucis  may  be  felt  the  pulsations  of  the  superficial  dorsalis  pedis  artery.  The  tendons  0}  the 
peronei,  though  less  prominent,  may  also  be  distinctly  palpated  beneath  the  external  malleolus 
during  dorsal  flexion.  In  the  sitting  posture  with  the  foot  resting  flat  upon  the  floor,  the  tip  of 
the  finger  may  be  placed  in  a  depression  upon  the  dorsum  of  the  foot  midway  between  the  lower 
extremities  of  the  malleoli,  and  in  this  depression  the  tendons  may  be  made  to  glide  beneath  the 
finger.  Just  above  this  depression  may  be  felt  the  lower  end  of  the  tibia  and  below  it  the 
astragalus;  it  consequently  marks  the  highest  level  of  the  ankle-joint.  In  this  situation  swelling 
and  fluctuation  may  occasionally  be  observed  in  inflammations  of  the  articulation.  At  the  inner 
margin  of  the  sole  the  tuberosity  of  the  scaphoid  bone  may  be  felt  without  difficulty,  below  and 
in  front  of  the  lower  end  of  the  internal  malleolus;  immediately  behind  this  point,  C  ho  part's 
articulation  (see  page  170)  may  be  opened.  At  the  outer  margin  of  the  sole,  opposite  to  the 
scaphoid  tubercle  but  somewhat  in  front  of  it,  may  be  felt  the  tuberosity  of  the  fifth  metatarsal 
bone,  which  is  just  in  front  of  Lis  franc' s  articulation  (see  page  170).  Further  anteriorly  the 
metatarsal  and  phalangeal  bones  may  be  palpated  upon  both  sides  of  the  foot ;  the  heads  of  the 
metatarsal  bones  indicate  the  location  of  the  metatarsophalangeal  articulations.  In  plantar 
flexion  the  heads  of  the  phalanges  may  be  felt  upon  the  dorsal  surface  of  the  toes;  they  mark 
the  situation  of  the  inter  phalangeal  joints. 

The  dorsalis  pedis  artery  (Fig.  85),  the  continuation  of  the  anterior  tibial,  passes  from  the 
anterior  annular  ligament  along  the  dorsal  surface  of  the  foot  in  the  first  interosseous  space.  It 
runs  anteriorly  from  a  point  midway  between  the  two  malleoli  and  divides  at  the  bases  of  the 
first  and  second  metatarsal  bones  into  a  larger  branch,  the  plantar  digital  (ramus  plantaris  pro- 
fundus), passing  between  the  first  and  second  metatarsal  bones  to  the  plantar  arch,  and  a  smaller 
branch,  the  dorsalis  hallucis  (A.  metatarsea  dorsalis  I),  running  forward  to  the  web  between  the 
great  and  the  second  toes.     To  the  outer  side,  the  dorsalis  pedis  gives  off  the  tarsal  artery  (A. 


Fig.  88. 


Fibula  ._ 


External  malleolus 

Calcaneo-astragaloid  articulation 

M.  peronaeus  brevis 

M.  peronaeus  longus 


Os  calcis  _ 


M.   flexor  accessorius 
M.  abductor  minimi  digiti 


First  metatarsal  bone 

First  tarsometatarsal  articulation 

Intertarsal,  tarsometatarsal,   and 

intermetatarsal  articulations 

Internal  cuneiform  bone 
Middle  cuneiform  bone 


Scaphoid  bone 
Astragaloscaphoid  articulation 


Astragalus 

Calcaneo-astragaloid  articu- 
lation 


Tibia 


Ankle-joint 
Internal  malleolus 
Astragalus 

M.  tibialis  post. 
M.  flexor  longus  digitorum 
M.  flexor  longus  hallucis 
Internal  plantar  nerve 
Internal  plantar  artery 
M.  abductor  hallucis 
External  plantar  nerve 
External  plantar  arteiy 

_    M.   flexor  brevis  digitorum 


Fig.  89. 


—  Fifth  metatarsal  bone 


Articulation  of  cuboid  with 
fourth  an  fifth  metatarsal  bones 
External  cuneiform  bone 

Cuboid  bone 
Calcaneocuboid  articulation 


Os  calcis 


Tuberosity  of  os  calcis 


THE  FOOT. 

Fig.  88.— A  frontal  section  of  the  talocrural  and  talocalcaneal  articulations. 
Fig.  89.— A  diagrammatic  representation  of  the  joints  of  the  foot. 


169 


tar  sea  lateralis),  passing  beneath  the  extensor  brevis  digitorum  and  anastomosing  with  the  next 
branch,  the  metatarsal  artery  (A.  arcuata),  which  runs  outward  upon  the  bases  of  the  metatarsal 
bones  and  gives  off  the  dorsal  metatarsal  arteries  for  the  second,  third,  and  fourth  metatarsal 
spaces  and  the  corresponding  sides  of  the  toes.  To  the  inner  side,  the  dorsalis  pedis  gives  off 
two  or  three  insignificant  vessels,  the  A  a.  tar  sea  mediates . 

The  nerves  of  the  dorsum  of  the  foot  (Fig.  85)  are:  (1)  The  musculocutaneous,  which  divides 
at  a  higher  level  into  an  external  and  an  internal  branch  (see  page  167).  They  supply  digital 
branches  for  all  of  the  toes  except  the  outer  side  of  the  little  toe  and  the  adjacent  surfaces  of 
the  great  and  second  toes.  The  latter  is  supplied  by  the  anterior  tibial;  the  outer  margin  of 
the  dorsum  of  the  foot  and  of  the  little  toe  is  supplied  by  the  short  saphenous,  which  is  known 
in  this  situation  as  the  N.  cutaneus  dorsi  pedis  lateralis.  All  three  nerves  inosculate  with  each 
other. 

Sole  of  the  Foot. — Beneath  the  tough  skin  of  the  sole  of  the  foot  there  is  a  thick  cushion 
of  fat  which  is  particularly  well  developed  posteriorly.  Beneath  this  fat  is  the  strong  plantar 
fascia,  which,  like  the  palmar  fascia,  gives  off  five  processes  for  the  sheaths  of  the  flexor  tendons 
and  the  skin  and  possesses  transverse  trabecular.  In  the  middle  of  the  foot  the  fascia  is  con- 
siderably thicker  than  at  the  sides  and  covers  the  flexor  brevis  digitorum  muscle,  furnishing  an 
origin  for  some  of  its  fibers.  The  external  plantar  artery  (see  page  167  and  Fig.  87)  passes  into 
the  sole  beneath  the  abductor  hallucis  and  then  runs  outward  between  the  flexor  brevis  digitorum 
and  the  flexor  accessorius;  the  vessel  then  curves  to  the  inner  side  of  the  foot  and  forms  the 
plantar  arch  by  anastomosing  with  the  communicating  branch  of  the  dorsalis  pedis.  The  plantar 
arch  lies  directly  upon  the  bases  of  the  second,  third,  and  fourth  metatarsal  bones  and  upon  the 
interosseous  muscles.  Anteriorly  it  gives  off  four  digital  branches  (Aa.  melatarsece  plantares) 
for  the  interosseous  spaces  and  the  corresponding  sides  of  the  toes,  while  the  outer  and  inner 
margins  of  the  sole  are  supplied  by  separate  branches  from  the  arch.  The  smaller  internal 
plantar  artery  runs  anteriorly  to  the  inner  side  of  the  abductor  hallucis  to  the  great  toe,  where 
it  usually  anastomoses  with  the  first  digital  branch  (A.  metatarsi  plantaris  I). 

Before  entering  the  sole  the  posterior  tibial  nerve  divides  into  the  external  and  the  internal 
plantar  nerves.  The  external  plantar  nerve  accompanies  the  external  plantar  artery  and  divides 
into  a  superficial  and  a  deep  branch  (Fig.  87).  The  superficial  branch  supplies  the  muscles  of 
the  ball  of  the  little  toe  and  gives  off  three  digital  nerves  to  the  sides  of  the  little  toe  and  to  the 
outer  side  of  the  fourth  toe.  The  deep  branch  follows  the  plantar  arch  into  the  depth  of  the 
sole  and  supplies  the  interosseous  muscles  and  the  adductor  hallucis.  The  internal  plantar 
nerve  runs  to  the  inner  side  of  the  flexor  brevis  digitorum,  supplies  the  muscles  of  the  ball  of 
the  great  toe  and  the  flexor  brevis  digitorum,  and  ends  in  seven  digital  nerves  which  supply 
both  sides  of  the  three  inner  toes  and  the  inner  side  of  the  fourth  toe. 

For  the  movements  of  the  foot  there  are  two  joints  which  are  worthy  of  particular  atten- 
tion: 

1.  The  ankle-joint,  or  talocrural  articulation  (Figs.  88  and  89),  between  the  leg  and  the 


170  TOPOGRAPHIC    AND    APPLIED    ANATOMY. 

astragalus ;  the  trochlea  and  the  lateral  surfaces  of  the  astragalus  are  surrounded  by  the  articular 
surface  of  the  lower  end  of  the  tibia  and  by  the  two  malleoli.  The  capsular  ligament  is 
attached  anteriorly  and  posteriorly  to  the  astragalus  at  a  slight  distance  from  its  articular  surface 
and  runs  to  the  margins  of  the  malleoli  and  of  the  articular  surface  of  the  tibia.  The  articular 
cavity  communicates  with  that  of  the  inferior  tibiofibular  articulation.  The  movements  of  the 
joint  are  those  of  dorsal  and  plantar  flexion. 

2.  The  talotarsal  articulation  (Figs.  88  and  89)  consists  of  two  separate  portions:  (a)  The 
posterior  calcaneo-astragaloid  articulation  (Artie,  talocalcanea),  between  the  posterior  articular 
surfaces  of  the  astragalus  and  of  the  os  calcis.  The  capsular  ligament  is  attached  close  to  the 
margins  of  the  articular  surfaces,  (b)  The  anterior  calcaneo-astragaloid  articulation  (Artie. 
talonavicularis),  between  the  middle  and  anterior  articular  surfaces  of  the  astragalus  and  of  the 
os  calcis,  and  also  between  the  head  of  the  astragalus  and  the  scaphoid  bone.  The  capsular 
ligament  is  attached  to  the  margins  of  the  cartilaginous  surfaces  and  is  strengthened  by  the 
superior  astragalonavicular  ligament  (ligamentum  talonavicular) .  The  movement  is  chiefly 
that  of  pronation  and  supination. 

The  remaining  joints  are: 

3.  The  calcaneocuboid  (Fig.  89),  between  the  corresponding  articular  surfaces  of  the  os 
calcis  and  of  the  cuboid  bone.  This  joint,  together  with  the  astragaloscaphoid,  although  sepa- 
rate anatomically,  forms  the  so-called  Chopart's  joint  (Artie,  tarsi  transversa). 

4.  The  intertarsal  articulations,  between  the  remaining  tarsal  bones. 

5.  The  tarsometatarsal  articulations,  Lisjranc's  joint  (the  second  metatarsal  bone  extends 
further  posteriorly  than  the  others).  This  articulation  usually  consists  of  three  separate  cavities 
(as  shown  in  Fig.  89),  of  which  the  middle  one  communicates  with  the  intertarsal  articulations 
and  with  the  joint  between  the  scaphoid  and  the  cuneiform  bones. 

6.  The  metatarsophalangeal  and  the  inter  phalangeal  articulations. 

These  articulations  are  strengthened  by  a  number  of  ligaments.  The  external  lateral  liga- 
ment is  composed  of  three  fasciculi:  The  anterior  astragalofibular  ligament,  from  the  external 
malleolus  to  the  outer  surface  of  the  astragalus;  the  posterior  astragalofibular  ligament,  from 
the  external  malleolus  to  a  tubercle  on  the  posterior  surface  of  the  os  calcis;  the  calcaneofibular 
ligament,  from  the  tip  of  the  external  malleolus  to  the  outer  surface  of  the  os  calcis. 

The  internal  lateral  ligament  (ligamentum  deltoideum)  radiates  from  the  internal  malleolus 
to  the  scaphoid,  astragalus,  and  calcaneum. 

The  astragalus  and  the  calcaneum  are  united  by  the  calcaneoastragaloid  ligaments.  Special 
mention  should  be  made  of  the  interosseous  ligament  which  unites  the  anterior  end  of  the  cal- 
caneum with  the  inferior  surface  of  the  neck  of  the  astragalus.  The  ligamentum  bifurcatum* 
is  situated  upon  the  dorsal  surface  and  unites  the  anterior  end  of  the  dorsal  surface  of  the  cal- 
caneum with  the  cuboid  and  scaphoid  bones. 

Upon  the  plantar  aspect  the  foot  is  strengthened  by  the  ligaments  proceeding  from  the 
os  calcis  and  running  to  the  scaphoid,  to  the  cuboid,  and  to  the  bases  of  the  metatarsal  bones. 
The  chief  of  these  is  the  long  plantar  ligament  passing  from  the  inferior  surface  of  the  os  calcis 
to  the  cuboid  and  to  the  metatarsal  bones.  The  inferior  calcaneonavicular  ligament  is  also  found 
in  this  situation. 

*  Superior  calcaneonavicular  +   internal  calcaneocuboid. 


REVIEW   QUESTIONS.  ijj 

REVIEW  QUESTIONS. 

Where  may  the  pulsations  of  the  femoral  artery  be  felt? 

How  may  the  location  of  the  acetabulum  be  projected  upon  the  surface  of  the  body? 

How  does  the  ligamentum  teres  of  the  hip-joint  manifest  its  importance  after  an  intracapsular 
fracture  of  the  neck  of  the  femur? 

Of  what  importance  is  the  attachment  of  the  capsular  ligament  of  the  hip  for  the  nature  of  (that 
is,  in  deciding  the  nature  of)  the  fractures  of  the  neck  of  the  femur? 

Where  are  the  weak  places  in  the  capsular  ligament  of  the  hip? 

What  bursa  frequently  communicates  with  the  hip- joint? 

From  what  regions  do  the  so-called  inguinal  glands  receive  their  lymph? 

What  landmarks  aid  in  the  location  of  the  sciatic  nerve? 

What  is  the  practical  significance  of  the  loose  connective  tissue  accompanying  the  sciatic  nerve? 

What  effect  may  a  posterior  dislocation  at  the  knee  or  a  fracture  of  the  lower  end  of  the  femur 
have  upon  the  popliteal  vessels  and  upon  the  internal  popliteal  nerve? 

What  are  the  important  bursas  communicating  with  the  knee-joint,  and  what  are  they  which  do 
not  communicate  with  this  articulation? 

What  relation  must  be  borne  in  mind  in  exposing  the  popliteal  artery? 

Where  may  the  posterior  tibial  artery  be  easily  ligated,  what  synovial  sheath  is  thereby  endangered, 
and  in  the  division  of  what  tendon  must  the  position  of  the  artery  be  remembered? 

How  may  the  position  of  the  ankle-joint  be  indicated  externally? 

What  landmarks  are  employed  to  find  the  lines  of  Chopart's  and  of  Lisfranc's  articulations? 


INDEX. 


Abdomen,  118 

contents  of,  128 

external  oblique  muscle  of,  120 

internal  oblique  muscle  of,  120 

skin  of,  120 
Abdominal  aorta,  142 
aneurysm  of,  142 

portion  of  ureter,  141 

regions,  lateral,  120 

ring,  external,  124 
internal,  124 

wall,  118 

anterior,  inner  surface  of,  123 
arteries  of,  121 

external  cutaneous  nerve  of,  123 
inspection  and  palpation  of,  1 19 
lipoma  of,  119 
muscles  of,  120 
nerves  of,  123 

palpation  and  inspection  of,  119 
tumors  of,  119 
veins  of,  122 
venae  comites  of,  122 
Abducent  nerve,  33,  47,  48 
Abscess  above  and  below  mylohyoid 
muscle,  54 

cerebellar,  from  suppuration  in  mid- 
dle ear,  59 

in  brain  from  suppuration  in  mid- 
dle ear,  59 

mammary,  94 

mediastinal,  rupturing  through  ster- 
nal foramen,  93 

of  cervical  lymphatic  glands,  64 

of  fat  behind  thyrohyoid  ligament, 
66 

of  hip-joint,  157 

of  kidney,  139 

of  larynx,  66 

of  liver,  130 

of  mediastinum,  104 

perinephritic,  141 

periproctitis  147 

perityphlitic,  137 

retropharyngeal,  58 


Abscess,   retropharyngeal,   from   dis- 
eases of  cervical  vertebras,  58 

subphrenic,  132 
Acetabulum,  156 
Acromioclavicular  articulation,  73 
Acromion,  92 

Acromiothoracic  artery,  74,  95 
Adam's  apple,  66 
Adductor  brevis  muscle,  160 

longus  muscle,  160 

magnus  muscle,  160 

muscles,  160 
Aditus  ad  laryngem,  58 
Alveolar  artery,  superior,  40 
Ampulla  recti,  150 
Anastomotica  magna  artery,  78 
Aneurysm,  aortic,  97 

of  abdominal  aorta,  142 

of  aortic  arch,  113 

of  ascending  aorta,  112 

of  descending  aorta,  114 
Anger,  vein  of,  26 
Angle,  lieno-renal,  133 

of  Ludwig,  90 

of  scapula,  inferior,  92 
internal,  92 

sternal,  90 
Angular  artery,  40 

vein,  40 
Ankle-joint,  169 
Annular  ligament,  anterior,  85 

posterior,  85 
Annulus  femoralis,  125 
Ansa  hypoglossi,  64 
Anterolateral  fontanelle,  20    . 
Anteversion  of  uterus,  152 
Antrum,  mastoid,  suppuration  in  mid- 
dle ear  extending  into,  59 

of  Highmore,  49,  51 
Anus,  artificial,  138 
Aorta,  abdominal,  142 
aneurysm  of,  142 

arch  of,  113 

aneurysm  of,  113 

ascending,  112 

173 


Aorta,  ascending,  aneurysm  of,  112 
descending,  aneurysm  of,  114 
thoracic,  ascending,  113 
stenosis  of,  97 
Aortic  aneurysm,  97 
Apertura  pyriformis,  48 
Apex,  cardiac,  107 
Apex-beat  of  heart,  90 
Arachnoid  membrane,  33 
villi  of,  33 
rupture  of,  33 
Arch  of  aorta,  113 
aneurysm  of,  113 
palmar,  deep,  86 
superficial,  86 
plantar,  169 
Arcuata  artery,  169 
Arcus  tendineus,  146 
venosus  juguli,  68 
Arm,  upper,  77 
Arteria  colica  dextra,  136 
media,  136 
sinistra,  136 
hepatica  propria,  130 
intestinales,  136 
Arterial  supply  of  brain,  33 
Artery,  acromiothoracic,  74,  95 
alveolar,  superior,  40 
anastomotica  magna,  78 
angular,  40 
arcuata,  169 
articular,  inferior,  163 

superior,  163 
articularis  genu  media,  163 
auditory,  internal,  34 
auricular,  posterior,  26 
axillary,  7;.  74 
azygos,  articular,  163 
basilar,  34 
brachial,  78,  80 
carotid,  common,  63,  68,  70 
right,  69 
external,  63 
internal,  26,  34,  63 

hemorrhage  from,  34,  60 


174 


INDEX. 


Artery,  central,  of  retina,  46 
cerebellar,  anterior  inferior,  34 

posterior  inferior,  34 

superior,  34 
cerebral,  anterior,  35 

middle,  35 

posterior,  34 
cervical,  ascending,  70 

deep,  70 
choroid,  anterior,  35 
ciliary,  long,  46 

short,  46 
circumflex,  anterior,  75 

external,  161 

posterior,  75 
colica  dextra,  136 

media,  136 

sinistra,  136 
comes  nervi  ischiadici,  159 

phrenici,  94,  99 
communicating,  posterior,  34,  35 
coronary,  113 

inferior,  40 

superior,  40 
dental,  inferior,  40 
dorsalis  hallucis,  168 

pedis,  167,  168 
superficial,  168 

scapulae,  74,  96 
epigastric,  deep,  121 

inferior,  121 

superficial,  121 

superior,  94 
ethmoidal,  anterior,  46 

posterior,  46 
facial,  39,  64,  65 
femoral,  155,  160,  161 

first  portion  of,  161 

second  portion  of,  161 

third  portion  of,  161 
frontal,  26,  46 
gastric,  129 
gastroduodenal,  130 
gastro-epiploica  sinistra,  130 
gluteal,  159 

hemorrhoidal,  superior,  136 
hepatic,  127,  129 
hypogastric,  154 
ileocolic,  136 

iliac,  circumflex,  deep,  122 
superficial,  121 

common,  142 
infraorbital,  40 
innominate,  69 


Artery,  intercostal,  96 
anterior,  94 
injuries  of,  96,  97 
relation  with  intercostal  grooves, 

96 
seven  lowermost,  121 
superior,  70,  96 
interosseous,  anterior,  83 
common,  83 
palmar,  86 
posterior,  83 
lachrymal,  46 
lingual,  39,  56,  64 
lumbar,  122 

main,   of  cranium,   points   of    en- 
trance, 21 
malleolar,  external,  167 

internal,  167 
mammary,  internal,  70,  93 

anterior  intercostal  branches  of, 

96 
injuries  of,  94 
maxillary,  internal,  39,  40 
meningeal,  middle,  29,  40 

anterior  branch,  method  of  ex- 
posing, 29 
hematoma  of,  29 
injuries  of,  29 

posterior    branch,    method    of 
exposing,  30 
mesenteric,  inferior,  136 

superior,  135 
metatarsal,  169 
metatarsea  dorsalis  I,  168 

plantaris,  169 
metatarsea  plantaris  I,  169 
musculophrenic,  94 
occipital,  26 
of  abdominal  wall,  121 
of  diaphragm,  99 
of  face,  39 
of  forearm,  83 
of  mammary  gland,  94 
of  nasal  cavity,  50 
of  scalp,  26 
of  stomach,  129 
ophthalmic,  34,  39,  46 
palatine,  ascending,  40 

posterior,  40 
pancreaticoduodenalis,  inferior,  136 
perforating,  anterior,  94 
pericardiaro-phrenic,  99 
peroneal,  167 
plantar,  digital,  168 


Artery,  plantar,  external,  167,  169 

internal,  167,  169 
popliteal,  163 
princeps  pollicis,  86 
profunda  femoris,  161 

inferior,  78 

superior,  78 
pterygopalatine,  40 
pudic,  deep  external,  158 

internal,  159 

superficial  external,  158 
pulmonary,  114 
pyloric,  129 
radial,  83,  86 

pulse  of,  82 
ramus  cervicovaginalis,  151 

plantaris  profundus,  168 
ranine,  56 

scapular,  posterior,  71 
sciatic,  159 
sigmoid,  136 
sphenopalatine,  40,  50 
splenic,  130 

subclavian,  62,  70 
branches  of,  70 
right,  69 
sublingual,  56 
submental,  40,  65 
subscapular,  74,  96 
superficialis  volae,  86 
supraorbital,  26,  46 
suprascapular,  70 
tarsal,  168 
tarsea  lateralis,  169 

mediales,  169 
temporal,  superficial,  26 
frontal  branch,  26 
parietal  branch,  26 
thoracic,  intercostal  branches  of,  96 

•ong.  75-  95 

superior,  73,  95 
thoracicodorsalis,  74,  96 
thyroid,  inferior,  70 

superior,  64 
tibial,  anterior,  163,  167 

posterior,  163,  167 
transversalis  colli,  70 
ulnar,  80,  83,  86 
vasa  intestini  tenuis,  136 
vertebral,  34,  70 
Articular  artery,  inferior,  163 

superior,  163 
Articularis  genu  media  artery,  163 
Articulation,  acromioclavicular,  73 


Articulation    between    pisiform    and 
cuneiform  bones,  88 

calcaneo-astragaloid,  anterior,  170 
posterior,  170 

carpometacarpal,  88 

Chopart's,  168 

intercarpal,  88 

intermetacarpal,  88 

interphalangeal,  170 

intertarsal,  170 

Lisfranc's,  168 

metatarsophalangeal,  168,  170 

of  metacarpal  bone  of  thumb  with 
trapezium,  88 

radiocarpal,  88 

radio-ulnar,  inferior,  88 

talocrural,  169 

talotarsal,  170 
Artificial  anus,  138 
Aryepiglottic  fold,  58 
Arytenoepiglottic  fold,  58 
Ascites,  123,  126,  131 
Astragalofibular    ligament,    anterior, 
170 
posterior,  170 
Astragalus,  168 

Atrophy,  pressure-,  of  sternum,  93 
Attic,  59 
Auditory  artery,  internal,  34 

nerve,  ^ 
Auricular  artery,  posterior,  26 

vein,  posterior,  27 
Auricularis  magnus  nerve,  68,  71 
Auriculotemporal  nerve,  27 
Auriculoventricular  orifices,  108 
Axilla,  74 

lymphatic  glands  of,  74 
Axillary  artery,  73,  74 

cavity,  74 

line,  90 

anterior,  90 
posterior,  90 

lymphatic  glands,  95 

vein,  73,  75 
Axis,  cardiac,  105 

celiac,  129 

costocervical,  70 

pelvic,  144 

thyroid,  70 
Azygos  articular  artery,  163 

Barrel-shaped  chest  of  emphysema, 

93 
Bartholin,  duct  of,  55 


INDEX. 

Base-line,  37 
Reid's,  37 
Basilar  artery,  34 
Basilic  vein,  79 
median,  79 
Biceps  flexor  cruris,  160 
muscle,  77 
tendon,  79,  162 
Bicipital  groove,  72,  77 
Black-heads,  50 
Bladder,  female,  151 
male,  147 

relation  of  rectum  to,  148 
rupture  of,  148 
Blood,  effusions  of,  in  subarachnoid 
space,  33 
venous,  from  brain,  18,  21 
Blood-supply  of  diaphragm,  99 
of  dura  mater  of  brain,  29 
of  palate,  57 
of  pericranium,  28 
of  scalp,  25 
Bone,  hyoid,  62 

metacarpal,  of  thumb,  with  trape- 
zium, articulation  of,  88 
pisiform   and   cuneiform,    articula- 
tion between,  88 
scaphoid,  168 

temporal,  tympanic  plate  of,  59 
Wormian,  20 
Bony  thorax,  92 
Bosom,  91 

Brachial  artery,  78,  80 
plexus,  73,  75,  97 

internal  cutaneous  nerve  of,  75 
lesser  internal  cutaneous  nerve  of, 

75 
Brachialis  anticus  muscle,  77 
Brain,   abscess  in,  from  suppuration 
in  middle  ear,  59 
arterial  supply  of,  ^^ 
dura  mater  of,  28 

blood-supply  of,  29 
middle  meningeal  artery  of,  29 
sinuses  of,  30 
membranes  of,  28 
nerves  of,  32 
pia  mater  of,  ^ 
venous  blood  from,  18,  21 
Breast,  chicken,  of  rachitis,  93 

funnel,  93 
Breathing,  costal,  103 
diaphragmatic,  103 
Bulbo-cavernosus  muscle,  I46>  '47 


!75 

Bulla  ethmoidalis,  53 
Bursa  anserina,  165 

between  semimembranosus  and  in- 
ner head  of  gastrocnemius  mus- 
cles, 165 

iliopectineal,  156 

infrapatellar,  deep,  165 

intratendinea  olecrani,  79 

mucosa  subscapularis,  76 

of  knee-joint,  165 

of  popliteus  muscle,  165 

omentalis,  125 

prepatellar,  165 

subcutaneous,  79,  165 
over  tubercle  of  tibia,  165 

subdeltoid,  77 

subfascialis,  165 

subtendinea,  165 

suprapatellar,  164,  165 

trochanterica,  158 
Buttocks,  muscles  of,  158 

Calcaneo-astragaloid  articulation, 
anterior,  170 
posterior,  170 
Calcaneocuboid  joint,  170 
Calcaneofibular  ligament,  170 
Calcaneonavicular  ligament,  inferior, 

170 
Canal,  carpal,  84,  86 
Hunter's,  160,  161 
obturator,  145,  146 
Canalis  adductorius,  160,  161 
Capsula  adiposa,  139 
Capsular  ligament  of  elbow-joint,  81 
of  hip-joint,  156 
of  knee-joint,  164 
of  shoulder-joint,  76 
Caput  Medusa,  123 
Carcinoma  of  esophagus,  115,  116 

of  rectum,  150 
Cardia,  128 
Cardiac  apex,  107 
axis,  105 

dulness,  absolute,  106 
line,  inferior,  107 
left,  107 
right,  107 
superior,  107 
transverse,  107 
Caries  of  base  of  cranium,  32 
Carotid  artery,  common,  63,  68,  70 
right,  69 
external,  63 


176 


INDEX. 


Carotid  artery,  internal,  26,  34,  63 
hemorrhage  from,  34,  60 
triangle,  63 
tubercle,  63 
Carpal  canal,  84,  86 
Carpometacarpal  articulations,  88 
Cartilage,  cricoid,  62 
semilunar,  164 
tarsal,  44 
thyroid,  62 
triangular,  49 
Caruncle,  sublingual,  55 
Catarrh  of  frontal  sinus,  19 
of  lateral  wall  of  nose,  54 
Cavernosa  urethrae,  149 
Cavernous  sinus,  31 
thrombosis,  31 
Cavum  oris,  54 
Retzii,  148 
tympani,  59 
Celiac  axis,  129 
Cells,  ethmoidal,  53 

of  mastoid  antrum,  suppuration  in 
middle  ear  extending  into,  59 
Central  artery  of  retina,  46 
Cephalic  vein,  73,  79 

median,  79 
Cerebellar  abscess  from  suppuration 
in  middle  ear,  59 
artery,  anterior  inferior,  34 
posterior  inferior,  34 
superior,  34 
Cerebral  artery,  anterior,  35 
middle,  35 
posterior,  34 
Cerebrospinal  fluid,  escape  from  ear, 

23 
Cervical  artery,  ascending,  70 
deep,  70 
lymphatic  glands,  abscess  of,  64 
plexus,  68,  71 
region,  anterior,  63 
lateral,  63,  68 
median,  63,  65 
vertebras,  diseases  of,  retropharyn- 
geal abscess  from,  58 
relation  of  pharynx  to,  58 
Chest,  barrel-shaped,  of  emphysema, 

93 
narrow,  of  phthisis,  93 
Chicken  breast  of  rachitis,  93 
Choanae  narium,  48 
Chopart's  articulation  (joint),  168,  170 
Choroid  artery,  anterior,  35 


Ciliary  artery,  long,  46 
short,  46 
ganglion,  48 
Circular  sinus,  31 
Circulus  venosus  Halleri,  95 
Circumflex  artery,  anterior,  75 
external,  161 
posterior,  75 
nerve,  75 

injury  of,  from  subcoracoid  dislo- 
cation, 73 
Cirrhosis  of  liver,  122 

Talma-Morrison    operation    for, 
123 
Cisternae  subarachnoideales,  3^ 
Clavicle,    fracture    of,    laceration    or 
compression  of  nerves  and  vessels 
after,  73 
sternal  end  of,  backward  dislocation 
of,  94 
Cleft  palate,  repairing,  57 
Coccygeal  vertebras,  145 
Colon,  ascending,  137 
descending,  138 
sigmoid,  138 
transverse,  137 
Colotomy,  lumbar,  138 
Comedones,  50 
Comes  arteriosus,  106 

nervi  ischiadici  artery,  159 
phrenici  artery,  94,  99 
Common  carotid  artery,  70 

right,  69 
Communicans  peronei  nerve,  163 

poplitei  nerve,  163 
Communicating  artery,  posterior,  34, 

35 
Condyloid  foramen,  posterior,  22 

ridges,  external,  79 
internal,  79 
Conjunctiva,  palpebral,  44 
Conjunctival  sac,  44 
Constrictor  cunni  muscle,  147 
Coracoacromial  ligament,  77 
Coracobrachialis  muscle,  77 
Coracohumeral  ligament,  77 
Coracoid  process,  73,  92 
Coronary  artery,  113 
inferior,  40 
superior,  40 

ligament,  126 

vein  of  stomach,  stasis  in,  123 
Costal  breathing,  103 

pleura,  100 


Costo-axillary  veins,  97 
Costocervical  axis,  70 
Costoclavicular  line,  90 
Costocoracoid  ligament,  73,  92 
Costo-mediastinal  sinus,  100 
Costo-phrenic  sinus,  100 
Cranial  fossa,  anterior,  35 
middle,  35 

fracture  of,  23 
posterior,  fracture  of,  24 
nerve,  seventh,  41 

exposure  of,  41 
nerves,  points  of  exit,  21 
region,  17 
Craniocerebral  topography,  35 
Cranium,  17 

arteries  of,  points  of  entrance,  21 
base  of,  17,  21 
caries  of,  32 
fracture  of,  32 
strong  portions  of,  23 
thin  portions  of,  19,  22 
tumors  of,  ^^ 
external  plate  of,  18 
internal  plate  of,  18 
thickness  of,  17 
vault  of,  17 
vertex  of,  17 
Crease,  gluteofemoral,  162 
Cribriform  fascia,  157 

plate  of  ethmoid,  fracture  of,  23 
Cricoid  cartilage,  62 
Cricothyroid  ligament,  62,  66 
Cricotomy,  66 
Crista  lachrymahs  anterior,  42 

posterior,  42 
Crucial  ligament,  anterior,  164 

posterior,  164 
Crural  fascia,  165 

nerve,  anterior,  123,  157,  161 
Crureus  muscle,  160 
Cubital  vein,  median,  79 
Cuneiform  and  pisiform  bones,  articu- 
lation between,  88 
Curvature,  spinal,  thoracic  deformities 

of,  93 
Curve,  pelvic,  144 
postpubic,  149 
sacral,  150 
subpubic,  149 
Cutaneous  nerve,  external,  of  abdom- 
inal wall,  123 
internal,  lesser,  of  brachial  plexus, 
75 


Cutaneous    nerve,    internal,    of    bra- 
chial plexus,  75 
of  elbow,  79 
Cutaneus     dorsi     pedis     intermedius 
nerve,  167 
lateralis  nerve,  169 
medialis  nerve,  167 
surae  lateralis  nerve,  163 
medialis  nerve,  163 
Cysts,  congenital,  of  mouth,  56 

dermoid,    congenital,    in    floor    of 
mouth,  56 


Deformities,  thoracic,  of  spinal  cur- 
vature, 93 
Deltoid  muscle,  72 
Dental  artery,  inferior,  40 

branch,  inferior,  of  superior  maxil- 
lary division  of  fifth  nerve,  56 
nerve,  inferior,  41 
resection  of,  41 
Dermoid  cysts,  congenital,  in  floor  of 

mouth,  56 
Descendens  hypoglossi  nerve,  64 
Diameter,    anteroposterior,    of   pelvic 
cavity,  144 
of  pelvic  inlet,  143 

outlet,  144 
of  plane  of  pelvic  contraction,  144 
internal  conjugate,  diagonal,  of  pel- 
vis, 144 
Diameters,  sagittal,  of  pelvis,  143 
Diaphragm,  98 
arteries  of,  99 
blood-supply  of,  99 
dome  of,  118 
phrenic  nerves  of,  99 
Diaphragma  pelvis,  146 
sells,  30 
urogenitale,  146 
Diaphragmatic  breathing,  103 
hernia,  99 
pleura,  99,  100 
Diploic  veins,  18 

Dislocation,  backward,  of  sternal  end 
of  clavicle,  94 
of  elbow-joint,  81 
of  hip-joint,  156 
subcoracoid,  73 

injury  of  circumflex  nerve  from, 

73 
Diverticula,    traction,    of    esophagus, 
116 


INDEX. 

Dorsal  nerve,  first,  97 
Dorsalis  hallucis  artery,  168 
linguae,  56 
nasi,  46 
pedis  artery,  167,  168 

superficial,  168 
scapulas  artery,  74,  96 
Dorso-radial  fossa,  85 
Dorsum    of    foot,    musculocutaneous 
nerve  of,  169 
nerves  of,  169 
Drum-membrane,  59 
Duct,  parotid,  41 
Ductus  choledochus,  127 

communis  choledochus,  132 
Dulness,  absolute  cardiac,  106 
Duodenum,  134 

ascending  part  of,  135 
descending  part  of,  135 
superior  part  of,  134 
ulcer  of,  135 
Dura  mater  of  brain,  28 
blood-supply  of,  29 
middle  meningeal  artery  of,  29 
sinuses  of,  30 
Dysphagia,  58,  66,  no 
Dyspnea,  58,  113 


Ear,  59 

escape  of  cerebrospinal  fluid  from, 

23 
middle,  suppuration  in,  abscess  in 
brain  from,  59 
cerebellar  abscess  from,  59 
extending    into    mastoid    an- 
trum, 59 
pyemia  from,  59 
sinus  thrombosis  from,  59 
Ear-orbit  line,  37 
Ejaculatory  ducts,  148 
Elbow,  internal  cutaneous  nerve  of,  79 
miner's,  79 
region  of,  79 
Elbow-joint,  81 

capsular  ligament  of,  81 
dislocation  of,  81 
Eminence,  iliopectineal,  157 
Eminentia  carpi  radialis,  84 
ulnaris,  84 
intercondylea  tibiae,  164 
Emissary  foramina,  22 
Emphysema,  barrel-shaped  chest  of, 
92 


177 

Empyema,  100 

of  gall-bladder,  131 
Epicondyles,  external,  79 

internal,  79 
Epigastric  artery,  deep,  121 
inferior,  121 
superficial,  121 
superior,  94 
region,  119 
vein,  superficial,  122 
Epigastrium,  119 
Epiglottic  tubercle,  66 
Epipericardium,  108 
Epitympanic  recess,  59 
Esophageal  varices,  123 
Esophagus,  67,  115 
carcinoma  of,  115,  116 
foreign  bodies  in,  115,  116 
hemorrhage  from,  116 
length  of,  115 

lymphatic  glands  alongside,  suppu- 
ration in,  67 
tumors  of,  67 
narrow  portions  of,  115 
pneumogastric  nerves  of,  116 
stenosis  of,  116 
suppuration  of,  116 
traction  diverticula  of,  116 
veins  of,  116 
Ethmoid,  cribriform  plate  of,  fracture 

of,  23 
Ethmoidal  artery,  anterior,  46 
posterior,  46 
cells,  53 
veins,  50 
Eustachian  cushion,  57 
Excavatio  recto-uterina,  152 
rectovesicalis,  148 
vesico-uterina,  151,  152 
Exophthalmos,  pulsating,  31 
Extensor  brevis  digitorum  muscle,  168 
pollicis  muscle,  83,  85 
carpi  radialis  brevior  muscle,  82 
Iongior  muscle,  82 
ulnaris  muscle,  82 
communis  digitorum  muscle,  82 
indicis  muscle,  83 
longus  digitorum  muscle,  166 
tendon  of,  168 
hallucis  muscle,  166 

tendon  of,  16S 
pollicis  muscle,  83,  85 
minimi  digiti  muscle,  82 
muscles  of  leg,  165 


178 


INDEX. 


Extensor  ossis  metacarpi  pollicis  mus- 
cle, 83,  85 

Extravisceral  portion  of  pelvic  space, 
146 

Extremity,  lower,  155 

Exudate,  pleural,  left-sided,  in 

Eye,  muscles  of,  45 

Eyeball,  45 

Eyelids,  44 


Face,  39 

arteries  of,  39 

nerves  of,  40 

veins  of,  40 
Facial  artery,  39,  64,  65 

nerve,  33,  65 

region,  39 

vein,  40 
Facies  diaphragmatica,  133 

gastrica,  128,  133 

lunata,  143,  156 

renalis,  133 
Falciform  ligament,  126,  132 
Fallopian  tube,  154 
False  pelvis,  143 
Falx  cerebelli,  30 

cerebri,  30 
Fascia,  cribriform,  157 

crural,  165 

iliac,  157 

iliopectineal,  157 

of  Retzius,  121 

palmar,  85 

rectovesical,  148 

transversalis,  121 

umbilical,  121 
Fat  behind  thyrohyoid  ligament,  63 
abscess  of,  66 

orbital,  45 
Fauces,  isthmus  of,  54 
Faucial  tonsil,  57 
Femoral  artery,  155,  160,  161 
first  portion  of,  161 
second  portion  of,  161 
third  portion  of,  161 

fossa,  125 

hernia,  157 

ring,  125,  157 

vessels,  157 
Femur,  fracture  of,  156 
Fibular  muscles,  165,  166 
Fifth  nerve,  superior  maxillary  divi- 
sion of,  inferior  dental  branch  of,  56 


Fissure  of  Larrey,  98 
Fistula  of  mouth,  56 

rectovaginal,  153 

urethrovaginal,  153 

vesicovaginal,  153 
Flap-like  wounds  of  scalp,  28 
Flexor  brevis  digitorum  muscle,  169 

carpi  radialis  muscle,  82 
ulnaris  muscle,  82 

longus  digitorum  muscle,  166 
hallucis  muscle,  166 
pollicis  muscle,  82 

muscles  of  leg,  165,  166 
of  thigh,  160 

profundus  digitorum  muscle,  82 

sublimis  digitorum  muscle,  82 
Flexura  perinealis,  150 

sacralis,  150 
Floating  spleen,  134 
Fold,  recto-uterine,  152 

vesico-uterine,  151,  152 
Fontanelle,  antero-lateral,  20 

frontal,  19 

large,  19 

occipital,  20 

postero-lateral,  20 
Fontanelles,  19 
Foot,  168 

dorsum  of,  musculocutaneous  nerve 
of,  169 
nerves  of,  169 

movements  of,  169 

sole  of,  169 

subcutaneous  venous  plexus  of,  168 
Foramen,  condyloid,  posterior,  22 

emissary,  22 

epiploicum,  125 

infraorbital,  41 

mastoid,  22 

occipital,  22 

of  Santorini,  22 

of  Winslow,  125 

parietal,  22 

sternal,  mediastinal  abscess  ruptur- 
ing through,  93 
medico-legal  aspects  of,  93 

supraorbital,  27,  42 

suprapyriform,  159 
Foramina,  infrapyriform,  146 

obturator,  145 

sacrosciatic,  145 

suprapyriform,  146 
Forearm,  81 

arteries  of,  83 


Forearm,  median  nerve  of,  injuries  of, 

83 
muscles  of,  82 
nerves  of,  83 
Foreign  bodies  in  esophagus,  115,  116 
Fossa  acetabuli,  143,  156 
cranial,  anterior,  35 

middle,  35 

fracture  of,  23 

posterior,  fracture  of,  24 
dorso-radial,  85 
femoral,  125 
iliopectinea,  160 
infraclavicular,  73,  92 
inguinal,  external,  124 

middle,  124 
ischiorectal,  146 
jugular,  60 
lachrymal,  42 
Mohrenheim's,  92 
nasal,  floor  of,  48 

inner  wall  of,  48 

outer  wall  of,  49 
navicularis,  149 
ovalis,  157 

Rosenmuller's,  53,  57 
saccilachrymalis,  42 
vena?  umbilicalis,  131 
vesicae  fellse,  131 
Fovea  femoralis,  125 
inguinalis  lateralis,  124 

medialis,  124 
supravesical,  124 
trochlearis,  42 
Fracture  of  base  of  cranium,  32 
of  clavicle,  laceration  or  compres- 
sion of  nerves  and  vessels  after, 

73 

of  cribriform  plate  of  ethmoid,  23 

of  femur,  156 

of  middle  cranial  fossa,  23 

of  nasal  roof,  23 

of  pelvic  walls,  145 

of  posterior  cranial  fossa,  24 

of  rib,  97 

of  sternum,  93 

of  tegmen  tympani,  23 
Frontal  artery,  26,  46 

branch  of  superficial  temporal  ar- 
tery, 26 

fontanelle,  19 

sinus,  19,  52 
catarrh  of,  19 

vein,  26 


Fundus  of  stomach,  128 
Funnel  breast,  93 
Furrow,  median,  anterior,  91 
posterior,  92 


Galea  aponeurotica,  24 
Gall-bladder,  131,  132 

empyema  of,  131 
Gall-stones,  131 
Ganglion,  ciliary,  48 

Meckel's,  41 
Gastric  artery,  129 
Gastrocnemius  muscle,  162,  166 
Gastrocolic  omentum,  126 
Gastroduodenal  artery,  130 
Gastro-epiploica  dextra  vein,  130 

sinistra  artery,  130 

vein,  130 
Gastrohepatic  omentum,  126 
Genitocrural  nerve,  123 
Gimbernat's  ligament,  157 
Gladiolus  and  manubrium,  synchon- 
drosis between,  93 
Glossopharyngeal  nerve,  65 

lingual  branch  of,  56 
Gluteal  artery,  159 

nerve,  superior,  159 
Gluteofemoral  crease,  162 
Gluteus  maximus  muscle,  158 

medius  muscle,  158 

minimus  muscle,  158 
Gracilis  muscle,  160 


Hand,  84 

palm  of,  synovial  sheath  of,  87 

tenosynovitis  in,  87 
Head,  17 

of  humerus,  72 
Hearing,  organ  of,  59 
Heart,  apex-beat  of,  90 

position  of,  105 
Hematemesis,  113 

Hematoma  of  middle  meningeal  ar- 
tery, 29 
Hematothorax,  100 
Hemiazygos  vein,  117 
Hemoptysis,  113 
Hemorrhage  after  tonsillotomy,  57 

from  esophagus,  116 

from  internal  carotid  artery,  34,  60 

from  nose,  cause  of,  23 

from  renal  vessels,  140 


INDEX. 

Hemorrhoidal  artery,  superior,  136 

plexus,  stasis  in,  123 
Hemothorax,  94,  97 
Hepatic  abscess,  130 

artery,  127,  129 
Hernia,  diaphragmatic,  99 

femoral,  157 

inguinal,  125 

inguinalis  obliqua  medialis,  125 

internal,  125 

of  linea  alba,  120 
Hiatus  adductorius,  160 

basilicus,  78 

semilunaris,  53 
Highmore,  antrum  of,  49,  51 
Hilus  pulmonis,  102 
Hip,  muscles  of,  158 

region  of,  155 
Hip-joint,  156 

abscess  of,  157 

capsular  ligament  of,  156 

dislocation  of,  156 
Hordeolum,  44 
Horizontal  line,  superior,  37 
Horner's  muscle,  44 
Humerus,  head  of,  72 

surgical  neck  of,  fracture  of,  com- 
pression  of   vessels   and    nerves 
after,  73 
Hunter,  canal  of,  160,  161 
Hydronephrosis,  142 
Hydrothorax,  100 
Hyoid  bone,  62 

muscle,  62 
Hypochondriac  regions,  119 
Hypogastric  artery,  154 

region,  119 
Hypoglossal  nerve,  56,  64 


Ileocolic  artery,  106 
Iliac  artery,  common,  142 
deep  circumflex,  122 
superficial  circumflex,  121 

fascia,  157 

vein,  superficial  circumflex,  122 
Iliofemoral  ligament,  156 
Iliohypogastric  nerve,  123,  139 
Ilio-inguinal  nerve,  123 
Uiopectineal  bursa,  156 

eminence,  157 

fascia,  157 

line,  143 
Iliopsoas  muscle,  157,  158 


179 

Iliotibial  band,  162 

Ilium,  superior  spinous  processes  of, 

119 
Impressio  colica,  131 
duodenalis,  135 
cesophagea,  131 
renalis,  131 
suprarenalis,  131,  141 
Incisura  acetabuli,  143,  156 
cardiaca,  102,  103 
interlobaris,  102,  103 
Infraclavicular  fossa,  73,  92 
Infrahyoid  region,  63 
Infraorbital  artery,  40 
foramen,  41 
nerve,  40 

exposure  of,  41 
resection  of,  for  neuralgia,  41 
Infrapatellar  bursa,  deep,  165 
Infrapyriform  foramina,  146 
Infraspinatus  muscle,  75,  76 
Inguinal  fossa,  external,  124 
middle,  124 
glands,  158 
hernia,  125 
lymphatic  glands,  158 
regions,  120 
Injuries  of  intercostal  arteries,  06,  97 
of  internal  mammary  artery,  94 
of  median  nerve  of  forearm,  83 
of  middle  meningeal  artery,  29 
of  musculospiral  nerve,  84 
Innominate  artery,  69 
vein,  112 
left,  68 
Interarvtenoid  notch,  58 
Intercarpal  articulations,  88 
Intercondyloid  line,  164 
Intercostal  artery,  96 
anterior,  94 
injuries  of,  96,  97 
relation  with  intercostal  grooves, 

96 
seven  lowermost,  121 
superior,  70,  96 
branches,  anterior,  of  internal  mam- 
mary artery,  96 
of  thoracic  aorta,  96 
grooves,  relation  of  intercostal  ar- 
teries with,  96 
nerves,  97 
vein,  superior,  117 
veins,  97 
Intermetacarpal  articulations,  88 


i8o 


INDEX. 


Intermuscular  septum,  anterior,  of  leg, 

165 
Interosseous  artery,  anterior,  83 
common,  83 
palmar,  86 
posterior,  83 
nerve,  anterior,  83 
posterior,  84 
Interphalangeal  articulation,  170 

joints,  168 
Interscapular  line,  103,  114 
Intertarsal  articulations,  170 
Intestine,  large,  136 

longitudinal  bands  of,  138 
small,  135 
Ischiocapsular  ligament,  156 
Ischiocavernosus  muscle.  147 
Ischiorectal  fossas,  146 
Ischium,  tuberosity  of,  155 
Isthmus  cerebri,  36 
of  fauces,  54 
of  thyroid  gland,  62 
in  children,  66 


Joint,  calcaneocuboid,  170 
Chopart's,  170 
interphalangeal,  168 
Lisfranc's,  170 
Jugular  fossa,  60 
vein,  anterior,  68 
external,  68 
internal,  64,  68,  71 
inferior  bulb  of,  71 


Kidney,  139 

abscess  of,  139 

hemorrhage  from,  140 

left,  140 

method  of  reaching  from  behind, 
141 

right,  140 

tumor  of,  140 
Knee,  region  of,  162 
Knee-joint,  163 

bursas  of,  165 

.capsular  ligament  of,  164 

internal  lateral  ligament  of,  164 

ligaments  of,  164 

long  external   lateral   ligament   of, 
164 

posterior  ligament  of,  165 


Kronlein,  line  of,  29,  37 
Kyphosis,  93 

Labrum  glenoidale,  156 
Laceration  of  vagina,  153 
Lachrymal  artery,  46 

canals,  45 

ducts,  45 

fossa,  42 

gland,  44 

nerve,  48 

papillas,  45 
Lacuna  musculorum,  157 

vasorum,  157 
Larrey,  fissure  of,  98 
Laryngeal  nerve,  inferior,  66 
left,  113 

portion  of  pharynx,  58 

region,  66 
Larynx,  abscess  of,  66 
-anterior  wall,  perichondritis  of,  66 

aperture  of,  superior,  58 
Latissimus  dorsi  muscle,  72 
Leg,  165 

anterior  intermuscular  septum  of, 

165 
extensor  muscles  of,  165 
flexor  muscles  of,  165,  166 
muscles  of,  165 
Levator  anguli  scapulae  muscle,  69 
palpebral  superioris  muscle,  46 
Lieno-renal  angle,  133 
Ligament,  annular,  anterior,  85 

posterior,  85 
anterior,  at  wrist,  88 
astragalofibular,  anterior,  170 

posterior,  170 
calcaneofibular,  170 
calcaneonavicular,  inferior,  170 
capsular,  of  elbow-joint,  81 

of  hip-joint,  156 

of  knee-joint,  164 

of  shoulder-joint,  76 
coracoacromial,  77 
coracohumeral,  77 
coronary,  126 
costocoracoid,  73,  92 
cricothyroid,  62,  66 
crucial,  anterior,  164 

posterior,  164 
falciform,  126,  132 
Gimbernat's,  157 
iliofemoral,  156 
ischiocapsular,  156 


Ligament,  lateral,  external,  at  wrist, 
88 
of  arm,  81 
%      of  knee-joint,  164 

internal,  at  wrist,  88 
of  arm,  81 

of  liver,  126 
long  external  lateral,  of  knee-joint, 

164 
of  knee-joint,  164 
orbicular,  81 
patellar,  164 
peritoneal,  125 
plantar,  long,  170 
posterior,  at  wrist,  88 

of  knee-joint,  165 
pubocapsular,  156 
round  (ligamentum  teres),  126 
sacrosciatic,  145 
suspensory,  of  liver,  126 

of  ovary,  154 
tarsal,  44 
thyrohyoid,  fat  behind,  65 

abscess  of,  66 
triangular,  of  pelvis,  146 
Ligamenta  cruciata,  164 

triangularia,  126 
Ligamentum  arteriosum,  114 
bifurcatum,  170 
carpi  radiatum,  88 
collaterale  fibulare,  164 
conicum,  62,  66 
coronarium  hepatis,  126 
deltoideum,  170 
duodenale,  125 
falciforme  hepatis,  126 
gastrocolicum,  127 
gastrolienale,  127,  128 
hepatoduodenale,  126,  127,  134 
hepatogastricum,  126 
infundibulopelvicum,  154 
laciniatum,  167 
patellae,  162 
phrenicolicum,  128 
phrenicolienale,  127 
popliteum  arcuatum,  164,  165 

obliquum,  164,  165 
posticum  Winslowii,  165 
talonavicular,  170 
teres,  126,  156 
umbilicale  latcrale,  154 
Line,  axillary,  90 

anterior,  90 

posterior,  90 


Line,  base-,  37 
Reid's,  37 
cardiac,  inferior,  107 
left,  107 
right,  107 
superior,  107 
transverse,  107 
costoclavicular,  90 
ear-orbit,  37 
horizontal,  superior,  37 
iliopectineal,  143 
intercondyloid,  164 
interscapular,  103,  114 
mammary,  90 
median,  anterior,  90 

posterior,  90 
of  Kronlein,  29,  37 
of  Richter-Monro,  122 
of  Rolando,  38 
of  Roser-Nelaton,  155 
of  Sylvius,  38 
parasternal,  90 
scapular,  90 
sternal,  90 
vertical,  anterior,  37 
middle,  38 
Linea  alba,  120 
hernia  of,  120 
glutsea  posterior,  158 
quadrati,  159 

semicircularis  Douglasi,  120 
semilunares,  119 
terminalis,  119 
Lingual  artery,  39,  56,  64 

branch  of  glossopharyngeal  nerve, 
56 
of  inferior  maxillary  nerve,  56 
Lipoma  of  abdominal  wall,  119 
Lisfranc's  articulation  (joint),  168,  170 
Liver,  130 

abscess  of,  130 
cirrhosis  of,  122 
coronary  ligament  of,  126 
inferior  surface  of,  130 
lateral  ligaments  of,  126 
lymphatic  glands  of,  131 
size  of,  in  children,  133 
suspensory  ligament  of,  126 
upper  convex  surface  of,  130 
Lobus  caudatus,  131 
Longitudinal  sinus,  inferior,  31 

superior,  30 
Longus  capitis  et  colli  muscles,  58 
Ludwig's  angle,  90 


INDEX. 

Lumbar  arteries,  122 
colotomy,  138 
plexus,  nerves  from,  123 
regions,  120 
veins,  ascending,  122 
Lungs,  99,  102 
adherent,  102 
grooves  of,  102 

respiratory  changes  in  position  of, 
102 
Lymphatic    glands  alongside   esoph- 
agus, suppuration  in,  67 
tumors  of,  67 
axillary,  74,  95 
cervical,  abscess  of,  64 
in  subinguinal  region,  155 
inguinal,  158 
of  liver,  131 
of  mamma,  95 
of  mediastinum,  104 
of  rectum,  150 
of  scalp,  27 
of  tongue,  56 
of  trachea,  115 
submaxillary,  65 
supraclavicular,  69 
Lymphoglandulae  subinguinales,  158 


Malleolar  artery,  external,  167 

internal,  167 
Mammary  abscess,  94 
artery,  internal,  70,  93 

anterior  intercostal  branches  of, 

96 
injuries  of,  94 
gland,  94 

arteries  of,  94 
lymphatic  vessels  of,  95 
nerves  of,  95 
neuralgia  of,  95 
tumors  of,  95 
veins  of,  95 
line,  90 
Manubrium  and  gladiolus,  synchon- 
drosis between,  93 
Margo  falciformis,  157 
Mastoid  antrum,  suppuration  in  mid- 
dle ear  extending  into,  59 
foramen,  22 
Maxillary  artery,  internal,  39,  40 
nerve,  inferior,  lingual  branch  of, 

56 
sinus,  49,  51 


l8l 

Maxillary  sinus,  tumors  of,  52 
McBurney's  point,  137 
Meatus,  149 
nasal,  49 
Meckel's  ganglion,  41 
Median  furrow,  anterior,  91 
posterior,  92 
line,  anterior,  90 

posterior,  90 
nerve,  78,  80,  83,  86,  87 
injuries  of,  83 
inner  head  of,  75 
outer  head  of,  75 
paralysis  of,  84 
Mediastinal  abscess  rupturing  through 
sternal  foramen,  93 
pleura,  100 
Mediastinum,  100,  104 
abscess  of,  104 
lymphatic  glands  of,  104 
suppuration  of,  104 
Meibomian  glands,  44 
Membrane,  arachnoid,  33 
villi  of,  33 
drum-,  59  t 

of  brain,  28 
sternal,  93 
Meningeal  artery,  middle,  29,  40 

anterior  branch,  method  of  ex- 
posing, 29 
hematoma  of,  29 
injuries  of,  29 

posterior    branch,    method    of 
exposing,  30 
Meniscus  lateralis,  164 

medialis,  164 
Mesenteric  artery,  inferior,  136 

superior,  135 
Mesentery,  125 

longest  part  of,  126 
Mesocolon,  125 

transverse,  138 
Mesogastric  region,  119 
Metacarpal  bone  of  thumb  with  tra- 
pezium, articulation  of,  88 
Metatarsal  artery,  169 
Metatarsea  dorsalis  artery  I,  168 
Metatarsea  plantaris  artery,  169 
Metatarsea  plantaris  artery  I,  169 
Metatarsophalangeal  articulation,  168, 

170 
Meteorismus,  131 

Middle  ear,  suppuration  in,  abscess 
in  brain  from,  59 


l82 


INDEX. 


Middle  ear,  suppuration  in,  cerebellar 
abscess  from,  59 
extending  into  mastoid  antrum, 

59 
pyemia  from,  59 
sinus  thrombosis  from,  59 
Miner's  elbow,  79 
Mohrenheim's  fossa,  92 
Motor  nerves   of  thoracic   wall,   97 
Mouth,  congenital  cysts  of,  56 
fistula  of,  56 

floor  of,   congenital  dermoid  cysts 
in,  56 
Muscle,  adductor  brevis,  160 
longus,  160 
magnus,  160 
biceps,  77 

flexor  cruris,  160 
brachialis  anticus,  77 
bulbo-cavernosus,  146,  147 
constrictor  cunni,  147 
coracobrachialis,  77 
crureus,  160 
deltoid,  72 

extensor  brevis  digitorum,  168 
pollicis,  83,  85 
carpi  radialis  brevior,  82 
longior,  82 
ulnaris,  82 
communis  digitorum,  82 
indicis,  83 

longus  digitorum,  166,  168 
hallucis,  166 

tendon  of,  168 
pollicis,  83,  85 
minimi  digiti,  82 
of  leg,  165 

ossis  metacarpi  pollicis,  83,  85 
fibular,  165,  166 
flexor  brevis  digitorum,  169 
carpi  radialis,  82 

ulnaris,  82 
longus  digitorum,  166 
hallucis,  166 
pollicis,  82 
of  leg,  165,  166 
of  thigh,  160 
profundus  digitorum,  82 
sublimis  digitorum,  82 
gastrocnemius,  162,  166 
gluteus  maximus,  158 
medius,  158 
minimus,  158 
gracilis,  160 


Muscle,  Horner's,  44 
hyoid,  62 

iliopsoas,  157,  158 
infraspinatus,  75,  76 
latissimus  dorsi,  72 
levator  ani  scapulae,  69 
mylohyoid,  54 

abscess  and  tumor  above  and  be- 
low, 54 
oblique,  external,  of  abdomen,  120 

inferior,  46 

internal,  of  abdomen,  120 

superior,  46 
obturator  externus,  159 

internus,  158,  159 
occipitofrontalis,  24 
of  abdominal  wall,  120 
of  buttocks,  158 
of  eye,  45 
of  forearm,  82 
of  hip,  158 
of  leg,  165 
of  neck,  63 
of  thigh,  159 
omohyoid,  69 

orbicularis  palpebrarum,  44 
pectineus,  160 
pectoralis  major,  72 

minor,  73 
perinei,  superficial  transversus,  147 
peroneus  brevis,  166 

longus,  166 

tendon  of,  168 

tertius,  166 
plantaris,  166 
popliteal,  bursa  of,  165 
popliteus,  166 
prevertebral,  62 
pronator  quadratus,  82 

radii  teres,  82 
pyriformis,  145,  158 
quadratus  femoris,  159 

lumborum,  121 
quadriceps,  160 

extensor  cruris,  159 
rectus,  159 

abdominis,  120 
sartorius,  159 
scalene,  62,  69 
semimembranosus,  160 
semitendinosus,  160 
soleus,  166 

sphincter  ani,  external,  164 
splenius  capitis  et  cervicis,  69 


Muscle,  sternocleidomastoid,  62 
subclavius,  73 
supinator  brevis,  82 

longus,  82 
supraspinatus,  75 
tensor  fasciae  latae,  159 
teres  minor,  76 
tibialis  anticus,  165 
tendon  of,  168 
posticus,  166 
transversalis  abdominis,  121 
triceps,  77 

surae,  165 
vastus  externus,  159 
intermedius,  160 
internus,  159 
Musculocutaneous  nerve  of  brachial 
plexus,  75 
of  dorsum  of  foot,  169 
of  elbow,  79 
Musculophrenic  artery,  94 
Musculospiral  nerve,  75,  78,  80,  84 
injury  of,  84 
paralysis  of,  79 
Mylohyoid  muscle,  54 

abscess    and    tumor    above   and 
below,  54 


Nares,  anterior,  48 

posterior,  48 
Nasal  cavity,  48 
arteries  of,  50 
nerves  of,  50 
veins  of,  50 
duct,  45 

fossa,  floor  of,  48 
inner  wall  of,  48 
outer  wall  of,  49 
meatuses,  49 
nerve,  48,  50 
superior,  51 
roof,  fracture  of,  23 
Naso-palatine  nerve,  51 
Naso-pharynx,  57 
Neck,  61 

muscles  of,  63 
skin  of,  63 

superficial  median  vein  of,  68 
tumors  of,  62 
Nerve,  abducent,  33,  47,  48 
auditory,  ^^ 

auricularis  magnus,  68,  71 
auriculotemporal,  27 


Nerve,  circumflex,  75 

injury  of,  from  subcoracoid  dislo- 
cation, 73 
communicans  peronei,  163 

poplitei,  163 
cranial,  points  of  exit,  21 
crural,  anterior,  123,  157,  161 
cutaneous,   external,  of  abdominal 
wall,  123 

internal,  75 
lesser,  75 
of  elbow,  79 
cutaneus   dorsi   pedis   intermedius, 
167 
lateralis,  169 
medialis,  167 

surae  lateralis,  163 
medialis,  163 
dental,  inferior,  41 

resection  of,  41 
descendens  hypoglossi,  64 
dorsal,  first,  97 
facial,  33,  65 
fifth,  superior  maxillary  division  of, 

inferior  dental  branch  of,  56 
from  lumbar  plexus,  123 
genitocrural,  123 
glossopharyngeal,  65 

lingual  branch  of,  56 
gluteal,  superior,  159 
hypoglossal,  56,  64 
iliohypogastric,  123,  139 
ilio-inguinal,  123 
infraorbital,  40 

exposure  of,  41 

resection  of,  for  neuralgia,  41 
intercostal,  97 
interosseous,  anterior,  83 

posterior,  84 
lachrymal,  48 
laryngeal,  inferior,  66 

left  inferior,  113 
maxillary,   inferior,   lingual  branch 

of,  56' 
median,  78,  80,  83,  86,  87 

injuries  of,  83 

inner  head  of,  75 

outer  head  of,  75 

paralysis  of,  84 
motor,  of  thoracic  wall,  97 
musculocutaneous,  75 

of  dorsum  of  foot,  169 

of  elbow,  79 
musculospiral,  75,  78,  80,  84 


INDEX. 

Nerve,  musculospiral,  injury  of,  84 

paralysis  of,  79 
nasal,  48,  50 

superior,  51 
nasopalatine,  51 
obturator,  162 

anterior  branch  of,  162 

posterior  branch  of,  162 
occipitalis  major,  28 
exposure  of,  28 

minor,  28,  68,  71 
oculomotor,  ^^,  47 
of  abdominal  wall,  123 
of  brain,  32 
of  dorsum  of  foot,  169 
of  face,  49 
of  forearm,  83 
of  mammary  gland,  95 
of  nasal  cavity,  50 
of  orbit,  46 
of  scalp,  27 
ophthalmic,  47 
optic,  45 
peroneal,  163 
phrenic,  71,  112,  116 

of  diaphragm,  99 
plantar,  external,  168,  169 

internal,  168,  169 
pneumogastric,  of  esophagus,  116 
popliteal,  external,  162,  163 

internal,  162,  163 
pudic,  internal,  159 
radial,  84 
saphenous,  long,  161,  163 

short,  163,  169 
sciatic,  161 

great,  159 

small,  159 
sensory,  of  thoracic  wall,  97 
seventh  cranial,  41 
exposure  of,  41 
spinal  accessory,  69 
splanchnic,  thoracic  portion  of,  117 
subcostalis,  139 
subscapular,  75 
superficialis  colli,  68,  71 
supraclavicular,  69,  71 
supraorbital,  27 

neurectomy  on,  27 
suprascapular,  75 
supratrochlear,  27 
sympathetic,    thoracic    portion    of, 

117 
thoracic,  long,  75,  96 


*«3 

Nerve,  thoracic,  twelfth,  139 
tibial,  anterior,  163,  167,  169 
musculocutaneous,  163 
posterior,  167 
trifacial,  ^3 
trochlear,  ^^,  47,  48 
ulnar,  75,  78,  79,  80,  84,  86,  87 

paralysis  of,  84 
vagus,  64 
Neuralgia  of  mammary  gland,  95 
resection  of  infraorbital  nerve  for, 

4i 
trifacial,  32 
Neurectomy  on  supraorbital  nerve,  27 
New-growths  in  lateral  wall  of  nose, 

54 
Nipple,  91 

Nose,  hemorrhage  from,  cause  of,  23 
lateral  wall  of,  catarrh  of,  54 

new-growths  in,  54 
skin  of,  50 


Oblique  muscle,  inferior,  46 

superior,  46 
Obturator  canal,  145,  146 

extern  us  muscle,  159 

foramina,  145 

internus  muscle,  158,  159 

nerve,  162 
anterior  branch  of,  162 
posterior  branch  of,  162 
Occipital  artery,  26 

fontanelle,  20 

foramen,  22 

sinus,  32 

vein,  27 
Occipitalis  major  nerve,  28 
exposure  of,  28 

minor  nerve,  28,  68,  71 
Occipitofrontalis  muscle,  24 
Oculomotor  nerve,  ^3,  47 
Olecranon,  79 
Olfactory  region,  50 
Omega  loop,  138 
Omentum,  gastrocolic,  126 

gastrohepatic,  126 
Omohyoid  muscle,  69 
Ophthalmic  artery,  34,  39,  46 

nerve,  47 

vein,  inferior,  46 
superior,  46 
Optic  nerve,  33,  45 
Oral  cavity,  54 


1 84 


INDEX. 


Oral  cavity,  vestibule  of,  54 
Orbicular  ligament,  81 
Orbicularis  palpebrarum  muscle,  44 
Orbit,  nerves  of,  46 
Orbital  cavity,  42 
inner  wall  of,  42 
lower  wall  of,  42 
outer  wall  of,  43 
upper  wall  of,  42 
veins  of,  46 
fat,  45 
septum,  44 
Ovary,  153 
suspensory  ligament  of,  154 


Pacchionian  bodies,  18,  ^^ 
Palate,  blood-supply  of,  57 

cleft,  repairing,  57 
Palatine  artery,  ascending,  40 

posterior,  40 
Palato-glossal  arch,  57 
Palato-pharyngeal  arch,  57 
Palm  of  hand,  synovial  sheaths  of,  87 
Palmar  arch,  deep,  86 
superficial,  86 

fascia,  85 

interosseous  arteries,  86 
Palpebral  conjunctiva,  44 
Pancreas,  134 
Pancreaticoduodenalis  artery,  inferior, 

136 
Papillas,  lachrymal,  45 
Paralysis  of  median  nerve,  84 

of  musculospiral  nerve,  79 

of  ulnar  nerve,  84 
Parasternal  line,  90 
Parietal  branch  of  superficial  temporal 
artery,  26 

foramen,  22 

pleura,  100 
Parotid  duct,  41,  54 

gland,  41 
Pars  laryngea,  58 

membranacea,  149 

nasalis  pharyngis,  57 

oralis,  57,  58 

prostatica,  149 
Parumbilical  veins,  122 

congestion  and  dilatation  of,  123 
Patella,  164 

"floats,"  162 
Patellar  ligament,  164 
Pectineus  muscle,  160 


Pectoralis  major  muscle,  72 

minor  muscle,  73 
Pelvic  axis,  144 
brim,  119 

cavity,  anteroposterior  diameter  of, 
144 
in  female,  150 
in  male,  147 
contraction,  plane  of,  anteroposte- 
rior diameter  of,  144 
curve,  144 
inclination,  145 
inlet,   anteroposterior  diameter  of, 

*43 

outlet,  anteroposterior  diameter  of, 
144 

space,  extravisceral  portion  of,  146 
vessels  and  nerves  of,  147 
visceral  portion  of,  146 

walls,  143 

fracture  of,  145 
Pelvis,  143 

diaphragma,  146 

false,  143 

internal  conjugate  diagonal  diam- 
eter of,  144 

obliquity  of,  145 

sagittal  diameters  of,  143 

triangular  ligament  of,  146 

true,  143,  145 
Perforating  artery,  anterior,  94 
Pericardiaco-phrenic  artery,  99 
Pericardial  cavity,  withdrawing  fluid 

from,  in 
Pericarditis,  no 
Pericardium,  104,  108 

relation  to  thoracic  wall,  in 

visceral,  108 
Perichondritis    of    anterior    wall    of 

larynx,  66 
Pericranium,  28 

blood-supply  of,  28 
Perinei  muscle,  superficial  transversus, 

M7 
Perinephritic  abscess,  141 
Periorbita,  27,  44 
Periproctitic  abscess,  147 
Perisplenitis,  133 
Peritoneal  cavity,  125 
lesser,  125 

ligaments,  125 

pockets,  139 

recesses,  139 
Peritoneum,  125 


Peritoneum,  female,  152 
Perityphlitic  abscess,  137 
Peroneal  artery,  167 

nerve,  163 
Peroneus  brevis  muscle,  166 

longus  muscle,  166 

muscle,  tendon  of,  168 

tertius  muscle,  166 
Pes  anserinus,  164 
Petrosal  sinus,  inferior,  31 

superior,  31 
Pharyngeal  recess,  57 

tonsil,  57 
Pharynx,  57 

laryngeal  portion  of,  58 

relation  to  cervical  vertebras,  58 

tumors  of,  59 
Phrenic  nerve,  71,  112,  116 

of  diaphragm,  99 
Phthisis,  narrow  chest  of,  93 
Pia  mater  of  brain,  33 
Pisiform  and  cuneiform  bones,  artic- 
ulation between,  88 
Pit  of  stomach,  91 
Plantar  arch,  169 

artery,  external,  167,  169 
internal,  167,  169 

digital  artery,  168 

ligament,  long,  170 

nerve,  external,  168,  169 
internal,  168,  169 
Plantaris  muscle,  166 
Pleura,  99 

costal,  100 

diaphragmatic,  99,  100 

dome  of,  100 

mediastinal,  100 

parietal,  100 

pericardiaca,  108 

relations  to  twelfth  rib,  101 

visceral,  100 
Pleural  cavity,  99 
opening  of,  97 

exudate,  left -sided,  in 

limits,  100 
Pleuritic  pain,  123 
Plexus,  brachial,  73,  75,  97 

internal  cutaneous  nerve  of,  75 
lesser  internal  cutaneous  nerve  of, 

75 
cervical,  68,  71 
hemorrhoidal,  stasis  in,  123 
lumbar,  nerves  from,  123 
subcutaneous  venous,  of  foot,  168 


INDEX. 


I85 


Plexus  venosus  mammilla,  95 
Plica  epigastrica,  121,  123 

nervi  laryngei,  58 

umbilicalis  media,  123 
Pneumogastric  nerves  of  esophagus, 

116 
Pneumopericardium,  108,  116 
Pneumothorax,  100,  111,  116,  130 
Point,  McBurney's,  137 
Pomum  adami,  62 
Popliteal  artery,  163 

nerve,  external,  162,  163 
internal,  162,  163 

space,     superficial     structures     of, 

163 

vein,  163 
Popliteus  muscle,  166 

bursa  of,  165 
Porta  hepatis,  122 
Portal  vein,  136 

Posterior  condyloid  foramen,  22 
Postero-lateral  fontanelle,  20 
Postpubic  curve,  149 
Prepatellar  bursas,  165 
Pressure-atrophy  of  sternum,  93 
Prevertebral  muscles,  62 
Princeps  pollicis  artery,  86 
Process,  coracoid,  92 
Profunda  artery,  inferior,  78 
superior,  78 

femoris  artery,  161 
Pronator  quadratus  muscle,  82 

radii  teres,  82 
Prostate,    enlargement    of,    effect    on 

urethra,  149 
Pterygopalatine  artery,  40 
Pubic  region,  120 
Pubocapsular  ligament,  156 
Pudic  artery,  deep  external,  158 
internal,  159 
superficial  external,  158 

nerve,  internal,  159 
Pulmonary  artery,  114 

veins,  114 
Pulsating  exophthalmos,  31 
Pulse  of  radial  artery,  82 
Puncta  lachrymalia,  45 
Pyemia  from  suppuration  in  middle 

ear,  59 
Pylephlebitis,  131 
Pyloric  artery,  129 
Pylorus,  128 
Pyopericardium,  108 
Pyothorax,  108,  in 


Pyriform  sinuses,  58 
Pyriformis  muscle,  145,  158 

Quadrangular  space,  76 
Quadratus  femoris  muscle,  159 

lumborum  muscle,  121 
Quadriceps    extensor    cruris    muscle, 

*59 

muscle,  160 

Rachitis,  chicken  breast  of,  93 
Radial  artery,  83,  86 
pulse  of,  82 

nerve,  84 
Radiocarpal  articulation,  88 
Radio-ulnar  articulation,  inferior,  88 
Radix  mesenterii,  126 
Ramus  cervicovaginalis  artery,  151 

plantaris  profundus  artery,  168 
Ranine  artery,  56 
Ranula,  56 
Recessus  bulbosus,  149 

duodenojejunalis,  139 

ileocacalis  inferior,  139 
superior,  139 

infundibuliformis,  53 

intersigmoideus,  139 
Recto-uterine  fold,  152 
Rectovaginal  fistula,  153 

septum,  153,  154 
Rectovesical  fascia,  148 
Rectum,  carcinoma  of,  150 

female,  154 

male,  150 

lymphatic  glands  of,  150 

relation  to  male  bladder,  148 
Rectus  abdominis  muscle,  120 

externus  muscle,  46 

inferior  muscle,  46 

internus  muscle,  46 

muscle,  159 

superior  muscle,  46 
Reid's  base-line,  37 
Resection  of  inferior  dental  nerve,  41 
of  infraorbital  nerve  for  neuralgia, 

4i 
of  portion  of  rib,  97 
subperiosteal,  97 
Respiratory    changes    in    position    of 

lungs,  102 
Rete  articulare  cubiti,  78 
carpi  dorsale,  8^,  86 
volare,  86 
Retina,  central  artery  of,  46 


Retropharyngeal  abscess,  58 

from  diseases  of  cervical  verte- 
bras, 58 
Retzius,  fascia  of,  121 

space  of,  148 
Rib,  fracture  of,  97 

resection  of  portion  of,  97 

twelfth,  relations  of  pleura  to,  101 
Ribs,  supernumerary,  91 
Richter-Monro  line,  122 
Rivinus,  duct  of,  55 
Rolando,  line  of,  38 
Rosenmiiller,  fossa  of,  53,  57 

gland  of,  157 
Roser-Nelaton's  line,  155 
Rotter's  dorso-radial  fossa,  85 
Round  ligament  (ligamentum  teres), 

126 
Rupture  of  arachnoid,  33 

of  male  bladder,  148 


Sacral  curve,  150 

triangle,  119 
Sacrosciatic  foramina,  145 

ligaments,  145 
Sacrum,  145 
Saddle-joint,  88 

Sagittal  diameters  of  pelvis,  143 
Santorini,  foramen  of,  22 
Saphenous  nerve,  long,  161,  163 
short,  163,  169 

vein,  internal,  157,  163 
long,  163 
short,  163 
Sartorius  muscle,  159 
Scalene  muscles,  62,  69 

slit,  69 

triangle,  69 
Scalp,  24 

arteries  of,  26 

blood  supply  of,  25 

flap-like  wounds  of,  28 

lymphatic  vessels  of,  27 

nerves  of,  27 

suppuration  beneath,  25 

suppuration  in,  25 

veins  of,  26 

wounds  of,  25 
Scaphoid  bone,  168 
Scapula,  angle  of,  inferior,  92 

internal,  92 
Scapular  artery,  posterior,  71 

line,  90 


i86 


INDEX. 


Scarpa's  triangle,  160 
Sciatic  artery,  159 

nerve,  161 
great,  159 
small,  159 
Scoliosis,  93 

Scrobiculus  cordis,  91,  131 
Sectio  alta,  151 
Sella  turcica,  tumors  of,  24 
Semilunar  cartilages,  164 
Semimembranosus  muscle,  160 
Seminal  vesicles,  148 
Semitendinosus  muscle,  160 
Sensory  nerves  of  thoracic  wall,  97 
Septum,    intermuscular,    anterior,    of 
leg,  165 

orbital,  44 

rectovaginal,  153,  154 

urethrovaginal,  152 

vesicovaginal,  151 
Seventh  cranial  nerve,  41 

exposure  of,  41 
Sheaths,  synovial,  of  palm  of  hand,  87 
Shoulder,  72 

anterior  region  of,  73 

posterior  region  of,  75 
Shoulder-joint,  76 

capsular  ligament  of,  76 
Sigmoid  arteries,  136 

colon,  138 

sinus,  30 
Sinus  alae  parvae,  32 

cavernous,  31 

circular,  31 

costo-mediastinal,  100 

costo-phrenic,  100 

frontal,  19,  52 
catarrh  of,  19 

lateral,  30,  31 

longitudinal,  inferior,  31 
superior,  30 

maxillary,  49,  51 
tumors  of,  52 

occipital,  32 

of  dura  mater  of  brain,  30 

of  Valsalva,  113 

petrosal,  inferior,  31 
superior,  31 

phrenicocostalis,  139 

pyriform,  58 

sigmoid,  30 

sphenoidal,  paired,  52 

sphenoparietal,  32 

straight,  31 


Sinus  thrombosis,  31 
cavernous,  31 
from  suppuration  in  middle  ear, 

59 

transversus  pericardii,  109 
Skin  of  abdomen,  120 

of  neck,  63 

of  nose,  50 
Skull,  17.     See  also  Cranium. 
Slit,  scalene,  69 
Snuff-box,  85,  86 
Socia  parotidis,  41 
Sole  of  foot,  169 
Soleus  muscle,  166 
Space  of  Tenon,  45 

of  Traube,  129 
Spatium  interfasciale,  45 
Spermatic  vessels,  141 
Spheno-ethmoidal  recess,  53 
Sphenoidal  sinuses,  paired,  52 
Sphenopalatine  artery,  40,  50 
Sphenoparietal  sinus,  32 
Sphincter  ani  muscle,  external,  146 

pylori,  134 
Spinal  accessory  nerve,  69 

curvature,   thoracic  deformities  of, 

93 
Spine,  92 
Splanchnic  nerves,  thoracic  portion  of, 

117 
Spleen,  133 

enlargement  of,  133 

floating,  134 

inflammation  of,  133 
Splenic  artery,  130 

vein,  133 
Splenius  capitis  et  cervicis,  69 
Stasis  in  coronary  vein  of  stomach,  123 

in  hemorrhoidal  plexus,  123 
Stenosis  of  esophagus,  116 

of  thoracic  aorta,  97 
Stenson's  duct  (parotid),  41,  54 
Sternal  angle,  90 

end  of  clavicle,  backward   disloca- 
tion of,  94 

foramen,   mediastinal  abscess  rup- 
turing through,  93 
medico-legal  aspects  of,  93 

line,  90 

membrane,  93 

region,  93 
Sternocleidomastoid  muscle,  62 
Sternum,  93 

pressure-atrophy  of,  93 


Stomach,  128 

anterior  surface  of,  128 

arteries  of,  129 

cardiac  opening  of,  128 

coronary  vein  of,  stasis  in,  123 

fundus  of,  128 

greater  curvature  of,  128 

pit  of,  91 

posterior  surface  of,  129 

pyloric  opening  of,  128 

veins  of,  130 
Straight  sinus,  31 
Striae  gravidarum,  120 
Stricture  of  male  urethra,  149 
Stye,  44 
Subarachnoid  space,  effusions  of  blood 

in.  33 
Subclavian  artery,  62,  70 
branches  of,  70 
right,  69 
groove,  113 
triangle,  69 
Subclavius  muscle,  73 
Subcoracoid  dislocation,  73 

injury  of  circumflex  nerve  from, 

73 
Subcostalis  nerve,  139 
Subcutaneous  bursa,  79 

over  tubercle  of  tibia,  165 
Subdeltoid  bursa,  77 
Subepicranial  tissue,  24 
Subhyoid  region,  65 
Subinguinal  region,  lymphatic  glands 

in.  *55 
Sublingual  artery,  56 

caruncle,  55 

gland,  55 
Submaxillary  gland,  65 

lymphatic  glands,  65 

triangle,  65 
Submental  artery,  40,  65 

region,  63 
Subperiosteal  resection,  97 
Subphrenic  abscess,  132 
Subpubic  curve,  149 
Subscapular  artery,  74,  96 

nerve,  75 
Sulcus  intertubercularis,  76 
Superficialis  colli  nerve,  68,  71 

volae  artery,  86 
Supernumerary  ribs,  91 

sutures,  20 
Supinator  brevis  muscle,  82 

longus  muscle,  82 


Suppuration  beneath  scalp,  25 

in  lymphatic  glands  alongside  esoph- 
agus, 67 
in  middle  ear,  abscess  in  brain  from, 
59 
cerebellar  abscess  from,  59 
extending  into  mastoid  antrum, 

59 
pyemia  from,  59 
sinus  thrombosis  from,  59 

in  scalp,  25 

in  thyroid  gland,  67 

of  esophagus,  116 

of  mediastinum,  104 
Supraclavicular  lymphatic  glands,  69 

nerves,  69,  71 
Suprahyoid  region,  63 
Supraorbital  artery,  26,  46 

foramen,  27,  42 

nerve,  27 

neurectomy  on,  27 
Suprapatellar  bursa,  164 
Suprapyriform  foramen,  146,  159 
Suprarenal  bodies,  141 
Suprascapular  artery,  70 

nerve,  75 
Supraspinatus  muscle,  75 
Supratrochlear  nerve,  27 
Supravesical  space,  148 
Suspensory  ligament  of  ovary,  154 
Sutures,  supernumerary,  20 
Sylvius,  line  of,  38 
Sympathetic   nerve,   thoracic   portion 

of,  117 
Synchondrosis    between    manubrium 

and  gladiolus,  93 
Synovial  sheaths  of  palm  of  hand,  87 


Tabatiere,  85,  86 

Taenia  coli,  138 

Talma-Morrison    operation    for    cir- 
rhosis, 123 

Talocrural  articulation,  169 

Talotarsal  articulation,  170 

Tarsal  artery,  168 
cartilage,  44 
ligaments,  44 

Tarsea  lateralis  artery,  169 
mediates  artery,  169 

Tegmen  tympani,  35,  59 
fracture  of,  23 

Temporal  artery,  superficial,  25 
frontal  branch,  26 


INDEX. 

Temporal  artery,  superficial,  parietal 
branch,  26 
bone,  tympanic  plate  of,  59 
vein,  27 
Temporo-maxillary  vein,  40 
posterior  division  of,  68 
Tendo  Achillis,  165 
Tendon,  biceps,  79,  162 
of  extensor  longus  digitorum  muscle, 
168 
hallucis  muscle,  168 
of  peroneus  muscle,  168 
of  tibialis  anticus  muscle,  168 
Tendovaginitis,  85 
Tenon,  space  of,  45 
Tenosynovitis  in  hand,  87 
Tensor  fasciae  latae  muscle,  159 
Tentorium  cerebelli,  30,  35 
Teres  minor,  76 
Thigh,  159 

flexor  muscles  of,  160 
muscles  of,  159 
Thoracic  aorta,  intercostal  branches 
of,  96 
stenosis  of,  97 
artery,  long,  75,  95 

superior,  73,  95 
ascending  aorta,  113 
deformities  of  spinal  curvature,  93 
duct,  117 
nerve,  long,  75,  96 

twelfth,  139 
space,  horizontal  lines  of,  90 
lower  boundary  of,  90 
upper  boundary  of,  90 
vertical  lines  of,  90 
wall,  89 
lateral,  94 
motor  nerves  of,  97 
relation  of  pericardium  to,  in 
sensory  nerves  of,  97 
veins  of,  97 
Thoracicodorsalis  artery,  74,  96 
Thoracocentesis,  10  r 
Thoracoepigastric  veins,  97 
Thorax,  89 
bony,  92 
contents  of,  99 
external  boundaries  of,  89 
inferior  boundary  of,  98 
inspection  and  palpation  of,  91 
internal  boundaries  of,  89 
lower  boundary  of,  89 
palpation  and  inspection  of,  91 


187 

Thorax,  upper  boundary  of,  89 
Thrombosis,  cavernous  sinus,  31 
sinus,  31 

from  suppuration  in  middle  ear, 
59 
Thumb,  metacarpal  bone  of,  with  tra- 
pezium, articulation  of,  88 
Thymus  gland,  104,  112 
Thyrohyoid  ligament,  fat  behind,  65 

abscess  of,  66 
Thyroid  artery,  inferior,  70 
superior,  64 
axis,  70 
cartilage,  62 

gland,  64,  66  » 

isthmus  of,  62 

in  children,  66 
suppuration  in,  67 
region,  66 
veins,  inferior,  67 
Thyrotomy,  66 
Tibia,  end  of,  168 
Tibial  artery,  anterior,  163,  167 
posterior,  163,  167 
nerve,  anterior,  163,  167,  169 
musculocutaneous,  163 
posterior,  167 
Tibialis  anticus  muscle,  165 
tendon  of,  168 
posticus  muscle,  166 
Tissue,  subepicranial,  34 
Tongue,  56 

lymphatic  vessels  of,  56 
Tonsil,  57 
faucial,  57 
pharyngeal,  57 
Tonsillotomy,  hemorrhage  after,  57 
Torus  tubarius,  53,  57 
Trachea,  67,  104,  114 
cervical  portion  of,  67 
lymphatic  glands  of,  115 
thoracic  portion  of,  67 
Tracheotomy,  high,  66 

low,  66 
Transversalis  abdominis  muscle,   121 
colli  artery,  70 
fascia,  121 
Traube,  space  of,  129 
Triangle,  carotid,  63 
sacral,  119 
scalene,  69 
Scarpa's,  160 
subclavian,  69 
submaxillary,  65 


INDEX. 


Triangular  cartilage,  49 

ligament  of  pelvis,  146 

space,  76 
Triceps  muscle,  77 

surae  muscle,  165 
Trifacial  nerve,  33 

neuralgia,  32 
Trigonum  femorale,  160 

omoclaviculare,  69 

urogenitale,  146 
Trochanter,  156 

great,  155 
Trochlea,  162 
Trochlear  nerve,  33,  47,  48 
True  pelvis,  143,  145 
Tubercle,  carotid,  63 

epiglottic,  66 
Tuberosity  of  ischium,  155 
Tumors  above  and  below  mylohyoid 
muscle,  54 

of  abdominal  wall,  119 

of  base  of  cranium,  33 

of  kidney,  140 

of   lymphatic   glands   alongside   of 
esophagus,  67 

of  mammary  gland,  95 

of  maxillary  sinus,  52 

of  neck,  62 

of  pharynx,  59 

of  sella  turcica,  24 
Twelfth    rib,   relations    of    pleura  to, 
101 

thoracic  nerve,  139 
Tympanic  plate  of  temporal  bone,  59 


Ulcer  of  duodenum,  135 
Ulnar  artery,  80,  83,  86 

nerve,  75,  78,  79,  80,  84,  86,  87 
paralysis  of,  84 
Umbilical  fascia,  121 
region,  central,  120 
Upper  extremity,  72 
Ureter,  abdominal  portion  of,  141 
female,  151 
male,  149 
Urethra,  female,  151 
male,  149 

effect  of  prostatic  hypertrophy  on, 

149 
narrow  places  of,  149 
stricture  of,  149 
wide  places  of,  149 
Urethrovaginal  fistula,  153 


Urethrovaginal  septum,  152 
Uterus,  anteversion  of,  152 

Vagina,  153 

areas  of,  153 

inferior  area  of,  153 

laceration  of,  153 

middle  area  of,  153 

mucosa  intertubercularis,  76 

superior  area  of,  153 
Vaginal  vault,  153 
Vagus  nerve,  64 
Valsalva,  sinuses  of,  113 
Varices,  esophageal,  123 
Vas  deferens,  124 
Vasa  intestini  tenuis  artery,  136 
Vascular  columns,  62 
Vastus  extern  us  muscle,  159 

intermedius  muscle,  160 

internus  muscle,  159 
Vein,  angular,  40 

auricular,  posterior,  27 

axillary,  73,  75 

basilic,  79 
median,  79 

cephalic,  73,  79 
median,  79 

coronary,  of  stomach,  stasis  in,  123 

costo-axillary,  97 

cubital,  median,  79 

diploic,  18 

epigastric,  superficial,  122 

ethmoidal,  50 

facial,  40 

frontal,  26 

gastro-epiploica  dextra,  130 
sinistra,  130 

hemiazygos,  117 

iliac,  circumflex,  superficial,  122 

innominate,  112 
left,  68 

intercostal,  97 
superior,  117 

jugular,  anterior,  68 
external,  68 
internal,  64,  68,  71 
inferior  bulb  of,  71 

lumbar,  ascending,  122 

occipital,  27 

of  abdominal  wall,  122 

of  anger,  26 

of  esophagus,  116 

of  face,  40 

of  mammary  gland,  95 


Vein  of  nasal  cavity,  50 
of  orbital  cavity,  46 
of  scalp,  26 
of  stomach,  130 
of  thoracic  wall,  97 
ophthalmic,  inferior,  46 

superior,  46 
parumbilical,  122 

congestion  and  dilatation  of,  123 
popliteal,  163 
portal,  136 
pulmonary,  114 
saphenous,  internal,  157,  163 
long,  163 
short,  163 
splenic,  133 

superficial  median,  of  neck,  68 
temporal,  27 
temporo-maxillary,  40 

posterior  division  of,  68 
thoraco-epigastric,  97 
thyroid,  inferior,  67 
Vena  azygos  major,  112,  114,  116,  122 
minor,  117 
cava,  inferior,  142 

superior,  112 
coronaria  ventriculi,  130 
hemiazygos,  104 

thoraco-epigastrica        tegumentosa 
longa,  97 
Venae  comites  of  abdominal  wall,  122 
Venous  blood  from  brain,  18,  21 
Vermiform  appendix,  137 

length  and  direction  of,  137 
relations   to   anterior   abdominal 
walls,  137 
process,  136 
Vertebra,  cervical,  diseases  of,  retro- 
pharyngeal abscess  from,  58 
relation  of  pharynx  to,  58 
coccygeal,  145 
prominens,  89 
Vertebral  artery,  34,  70 
Vertical  line,  anterior,  37 

middle,  38 
Vesicles,  seminal,  148 
Vesico-uterine  fold,  151,  152 
Vesicovaginal  fistula,  153 

septum,  151 
Vestibule  of  oral  cavity,  54 
Vestibulum  nasi,  50 

oris,  54 
Vibrissa;,  50 
Villi  of  arachnoid  membrane,  33 


INDEX. 


189 


Visceral  columns,  62 

pericardium,  108 

pleura,  100 

portion  of  pelvic  space,  146 
Vomer,  49 


Wharton,  duct  of,  55 
Winslow,  foramen  of,  125 
Wormian  bones,  20 
Wounds,  flap-like,  of  scalp,  28 
of  scalp,  25 


Wrist,  anterior  ligament  at,  88 
external  lateral  ligament  at,  88 
internal  lateral  ligament  at,  88 
posterior  ligament  at,  88 


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James,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  University, 
New  York.     Octavo  of  806  pages. 

Diseases  Of  the  Blood   [Anemia,  Chlorosis,  Leukemia,  and  Pseudoleukemia) 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of  Char- 
lottenburg ;  Dr.  K.  von  Noorden,  of  Frankfort-on-the-Main  ;  and  Dr. 
Felix  Pinkus,  of  Berlin.  The  entire  volume  edited,  with  additions,  by  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 
Octavo  of  700  pages,  with  text-cuts  and  1 3  full-page  plates,  5  in  colors. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstern,  of  Cologne. 
The  entire  volume  edited,  with  additions,  by  Ronald  Ross,  F.  R.  C.  S.  (Eng.), 
D.  P.  H.,  F.  R.  S.,  Major,  Indian  Medical  Service,  retired;  Walter  Myers, 
Lecturer,  Liverpool  School  of  Tropical  Medicine,  Liverpool  ;  and  Alfred 
S.  Grunbaum,  M.  D.,  F.  R.  C.  P.,  Lecturer  on  Experimental  Medicine,  Uni- 
versity of  Liverpool,  Eng.  Octavo  of  700  pages,  with  7  full-page  lithographic 
plates  in  colors. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator,  of  Berlin,  and  Dr.  M.  Litten,  of  Berlin.  The  entire 
volume  edited,  with  additions,  by  James  B.  Herrick,  M.  D.,  Professor  of  the 
Practice  of  Medicine,  Rush  Medical  College.     Octavo  of  800  pages,  illust. 

Diseases  of  the  Heart 

By  Prof.  Dr.  L.  von  Schrotter,  of  Vienna  ;  Prof.  Dr.  Th.  von  Jur- 
gensen,  of  Tubingen  ;  Prof.  Dr.  L.  Krehl,  of  Greifswald  ;  and  Prof.  Dr. 
H.  Vierordt,  of  Tubingen.  The  entire  volume  edited,  with  additions,  by 
George  Dock,  M.  D.,  Professor  of  Theory  and  Practice  of  Medicine  and 
Clinical  Medicine,  University  of  Michigan,  Ann  Arbor.  Octavo  of  about  1000 
pages,  with  72  text  illustrations  and  6  colored  plates. 


SOME    PRESS    OPINIONS 


London  Lancet  ( Typhoid  volume) 

"  We  welcome  the  translation  into  English  of 'this  excellent  practice  of  medicine.     The 
first  volume  contains  a  vast  amount  of  useful  information,  and  the  forthcoming  volumes  are 
awaited  with  interest." 
Journal  American  Medical  Association (  Tuberculosis  volume) 

"We  know  of  no  single  treatise  covering  the  subject  so  thoroughly  in  all  its  aspects  as 
this  great  German   work.  ...   It   is  one   of  the   most  exhaustive,  practical,  and  satisfactory 
works  on  the  subject  of  tuberculosis." 
Medical  News,  New  York  {Liver  volume) 

"  Leaves  nothing  to  be  desired  in  the  way  of  completeness  of  information,  orderly  arrange- 
ment of  the  text,  thoroughgoing  up-to-dateness,  handiness  for  reference,  and  exhaustive  dis- 
cussion of  the  subjects  treated." 

EACH  VOLUME  IS  COMPLETE  IN  ITSELF  AND  IS  SOLD  SEPARATELY 


THE  PRACTICE   OF  MEDICINE 


Anders' 
Practice  of  Medicine 

Sixth  Revised  Edition— Recently  Issued 


A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1295  pages,  fully  illustrated.  Cloth,  $5.50  net;  Sheep 
or  Half  Morocco,  $6.50  net. 

SIX   EDITIONS   IN   SIX  YEARS 

The  success  of  this  work  as  a  text-book  and  as  a  practical  guide  for  physi- 
cians has  been  truly  phenomenal,  six  large  editions  having  been  called  for 
in  as  many  years.  The  rapid  exhaustion  of  each  edition  has  made  it  possible 
to  keep  the  book  absolutely  abreast  of  the  times,  so  that  Anders"  Practice  has 
become  justly  celebrated  as  the  most  up-to-date  work  on  practice.  In  this 
edition  Malaria,  Yellow  Fever,  Bacillary  Dysentery,  Cholecystitis,  and  the  use  of 
the  X-rays  in  Diagnosis  and  Treatment  have  been  fully  discussed,  incorporating  the 
results  of  the  most  recent  investigations.  Among  the  new  subjects  introduced  are 
Paratyphoid  Fever,  the  Fourth  Disease,  Trypanosomiasis,  Orthostatic  Albuminuria, 
Transcortical  Aphasia,  Adiposis  Dolorosa,  and  Amaurotic  Family  Idiocy,  particu- 
lar attention  being  paid  to  clinical  character,  diagnosis,  and  treatment. 


PERSONAL  OPINIONS 


James  C  Wilson,  M.  D., 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Jefferson  Medical  College 

Philadelphia. 
'■It   is  an   excellent   book-concise,  comprehensive,  thorough,  and  up-to-date.     It   is   a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelph.a-to  us. 

A.  C  Cowperthwah,  M.  D., 

President  Illinois  Homeopathic  Medical  Association. 

■•  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough  and  fully  up-to-date 
in  everything.     I  consider  it  a  great  credit  to  both  the  author  and  the  pubhshers. 

Rulletin  of  the  Johns  Hopkins  Hospital 

r"  e  uccess  of  this  work  is  well  deserved.  ...  The  sections  on  treatment  are  excel.nt 
and  add  greatly  to  the  value  of  this  work.  Dr.  Anders  is  to  be  congratulated  on  the  contmued 
success  of  his  text-book." 


SAUNDERS  BOOKS   ON 


Pusey  and  Caldwell  on 

X-Rays 
in  Therapeutics  and  Diagnosis 


The  Practical  Application  of  the  Rontgen  Rays  in  Therapeutics 
and  Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor 
of  Dermatology  in  the  University  of  Illinois ;  and  Eugene  W.  Cald- 
well, B.  S.,  Director  of  the  Edward  N.  Gibbs  X-Ray  Memorial  Labo- 
ratory of  the  University  and  Bellevue  Hospital  Medical  College,  New 
York.  Handsome  octavo  of  625  pages,  with  200  illustrations,  nearly 
all  clinical.     Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

RECENTLY  ISSUED -NEW  (2d)  EDITION,  REVISED  AND  ENLARGED 
TWO  LARGE  EDITIONS  IN  ONE  YEAR 

Two  large  editions  of  this  work  within  a  year  testify  to  its  practical  value  to 
both  the  specialist  and  general  practitioner.  Throughout  the  work  it  has  been 
the  aim  of  the  authors  to  elucidate  the  practical  aspects  of  the  subject,  and  to 
this  end  the  text  has  been  beautifully  illustrated  with  clinical  pictures,  showing 
the  condition  before  the  use  of  the  X-rays,  at  various  stages  of  their  application, 
and  the  final  therapeutic  result  obtained.  Details  are  also  given  regarding  the  use 
and  management  of  the  apparatus  necessary  for  X-ray  work,  illustrating  the 
descriptions  with  instructive  photographs  and  drawings.  In  making  the  revision 
the  histories  of  the  cases  cited  have  been  brought  down  to  the  present  time. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Journal  of  Dermatology 

"  The  most  complete  and  up-to-date  contribution  on  the  subject  of  the  therapeutic  action 
of  the  Rontgen  rays  which  has  been  published  in  English." 

Boston  Medical  and  Surgical  Journal 

"  It  is  indispensable  to  those  who  use  the  X-rays  as  a  therapeutic  agent ;  and  its  illustrations 
are  so  numerous  .  .  .  that  it  becomes  valuable  to  every  one." 

New  York  Medical  Journal 

"  We  have  nothing  but  praise  for  this  volume,  the  combined  work  of  two  authors  than 
whom  no  one  is  better  fitted  by  training  or  experience  to  write  in  his  individual  field." 


PRACTICE   OF  MEDICINE. 


Sahli's  Clinical  Diagnosis 

Clinical  Diagnosis.  By  Prof.  H.  Sahli,  of  Bern.  Edited,  with 
additions,  by  Francis  P.  Kinnicutt,  M.  D.,  Professor  of  Clinical  Medi- 
cine, Columbia  University,  N.  Y.;  and  Nath'l  Bowditch  Potter,  M.  D., 
Visiting  Physician  to  the  City  Hospital  and  to  the  French  Hospital ; 
and  Consulting  Physician  to  the  Manhattan  State  Hospital,  N.  Y. 
Octavo  of  1 1  oo  pages,  profusely  illustrated. 

READY   SOON 

Dr.  Sahli's  great  work,  upon  its  publication  in  German,  was  immediately 
recognized  as  the  most  important  work  in  its  field.  Not  only  are  all  methods 
of  examination  for  the  purpose  of  diagnosis  exhaustively  considered,  but  the  ex- 
planation of  clinical  phenomena  is  given  and  discussed  from  physiologic  as  well 
as  pathologic  points  of  view.  The  examinations  of  the  stomach,  sputum,  feces, 
urine,  and  blood  are  exhaustively  treated.  In  the  chemical  examination  much 
attention  is  directed  to  describing  methods  ;  and  this  is  done  so  exactly  that  it 
will  be  possible  for  the  clinician  to  work  according  to  these  directions.  This 
American  edition  will  contain  all  the  new  matter  of  the  second  German  edition, 
with  which  it  will  simultaneously  appear. 

Friedenwald  and  Ruhrah 
on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Clinical  Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.     Octavo  of  689  pages.     Cloth,  £4.00  net. 

JUST  ISSUED 

This  work  contains  a  complete  account  of  food-stuffs,  their  uses,  and  chemical 
composition.  Dietetic  management  in  all  diseases  in  which  diet  plays  a  part  in 
treatment  is  carefully  considered,  the  articles  on  diet  in  diseases  of  the  digestive 
organs  containing  numerous  diet-lists  and  explicit  instructions  for  administration. 
The  feeding  of  infants  and  children,  of  patients  before  and  after  anesthesia  and 
surgical  operations,  and  the  latest  methods  of  feeding  after  gastro-intestinal 
operations  are  all  taken  up  in  detail.  The  subject  of  nutrient  enemata  is  given 
completely  with  recipes  and  full  instructions  as  to  technic. 


SAUNDERS'  BOOKS  ON 


Rolleston  on  the  Liver 


Diseases   of    the    Liver,    Gall-bladder,    and    Bile-ducts.     By    H. 

D.  Rolleston,  M.  D.  (Cantab),  F.  R.  C.  P.,  Physician  to  St.  George's 
Hospital,  London,  England.  Octavo  volume  of  794  pages,  fully  illus- 
trated, including  a  number  in  colors.     Cloth,  $6.00  net. 

ENTIRELY  NEW— JUST  ISSUED 

This  work  covers  the  entire  field  of  diseases  of  the  liver,  and  is  the  most 
voluminous  work  on  this  subject  in  English.  Dr.  Rolleston  has  for  many  years 
past  devoted  his  time  exclusively  to  diseases  of  the  digestive  organs,  and  any- 
thing from  his  pen,  therefore,  is  authoritative  and  practical.  Special  attention  is 
given  to  pathology  and  treatment,  the  former  being  most  profusely  illustrated 
both  with  pictures  of  the  gross  appearances  and  with  microphotographs.  There 
are  also  a  number  of  exceptionally  beautiful  and  accurate  colored  plates.  Dr. 
Rolleston' s  work  will  become  the  authority  on  diseases  of  the  liver. 


Boston's 
Clinical  Diagnosis 

Clinical  Diagnosis.  By  L.  Napoleon  Boston,  M.  D.,  Associate  in 
Medicine  and  Director  of  the  Clinical  Laboratories,  Medico-Chirurgi- 
cal  College,  Philadelphia.  Octavo  of  549  pages,  with  320  illustrations, 
many  in  colors.     Cloth,  $4.00  net. 

A   NEW   WORK— JUST  ISSUED 


The  clinical  examination  of  sputum,  feces,  blood,  etc.  has  assumed  such  an  im- 
portant place  in  practice  that  a  thorough  knowledge  of  the  significance  of  chemic 
and  microscopic  laboratory  findings  becomes  absolutely  necessary  to  success- 
ful therapeusis.  Dr.  Boston  here  presents  a  practical  manual  of  the  clinical  and 
laboratory  examinations  which  furnish  a  guide  to  correct  diagnosis,  giving  only 
such  methods,  however,  which  can  be  carried  out  by  the  busy  practitioner  in  his 
office  as  well  as  by  the  student  in  the  laboratory.  The  chapter  on  Serum  Diagno- 
sis is  particularly  complete. 


MATERIA   MEDIC  A. 


GET  A  •  THE  NEW 

the  best         American         standard 
Illustrated   Dictionary 

Third  Revised  Edition — Recently  Issued 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches ;  with  over  ioo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Dorland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

THREE  EDITIONS  IN  THREE  YEARS— WITH  1500  NEW  TERMS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  I  % 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  fifteen  hundred 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  100  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

■•  Dr.  Dorlands  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it.' 

Roswell  Park,  M.  D.,  

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  UmversUy  of 

-  I  ^acknowledge  my  astonishment  at  seeing  how  much  he  ^^^^^ 
tivelv  small  space.     I  find  nothing  to  criticize,  very  much  to  commend,  and  was  mterested 
finding  some  of  the  new  words  which  are  not  in  other  recent  d.ct,onanes. 


io  SAUNDERS'  BOOKS   ON 

Stevens'  Materia  Medica 
and  Therapeutics 


A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics.     By 

A.  A.  Stevens,  A.  M\,  M.  D.,  Lecturer  on  Physical  Diagnosis  in  the 
University  of  Pennsylvania.  Handsome  octavo  volume  of  663  pages, 
Cloth,  #3.50  net. 

JUST  ISSUED— THIRD   EDITION,  REWRITTEN   AND   ENLARGED 

Since  the  appearance  of  the  last  edition  of  this  book  such  rapid  advances 
have  been  made  in  Materia  Medica,  Therapeutics,  and  the  allied  sciences  that 
the  author  felt  it  imperative  to  rewrite  the  work  entirely.  All  the  newer  reme- 
dies that  have  won  approval  by  recognized  authorities  have  been  incorporated, 
and  their  therapeutic  properties  fully  discussed,  thus  bringing  the  book  absolutely 
down  to  date.  The  work  includes  the  following  sections  :  Physiologic  Action  of 
Drugs  ;  Drugs  ;  Remedial  Measures  other  than  Drugs  ;  Applied  Therapeutics  ; 
Incompatibility  in  Prescriptions  ;  Table  of  Doses  ;  Index  of  Drugs  ;  and  Index 
of  Diseases  ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 


OPINIONS  OF  THE  MEDICAL  PRESS 


University  Medical  Magazine 

"The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work  .  .  . 
and  it  will  be  found  a  reliable  guide  and  sufficiently  comprehensive  for  the  physician  in 
practice." 

Bristol  Medico-Chirurgical  Journal,  Bristol 

"This  addition  to  the  numerous  works  on  Therapeutics  is  distinctly  a  good  one.  ...  It 
is  to  be  recommended  as  being  systematic,  clear,  concise,  very  fairly  up  to  date,  and  carefully 
indexed." 


Monro's  Manual  of  Medicine  just  issued 

Manual  of  Medicine.  By  Thomas  Kirkpatrick  Monro,  M.  A.,  M.  D., 
Fellow  of,  and  Examiner  to,  the  Faculty  of  Physicians  and  Surgeons, 
England  ;  Glasgow  Physician  to  Glasgow  Royal  Infirmary,  Glasgow,  etc 
Octavo  volume  of  901  pages,  illustrated.     Cloth,  $5.00  net. 


THE  PRACTICE   OF  MEDICINE. 


Hatcher  and  So  11m ami's 
Materia  Medica 

A  Text-Book  of  Materia  Medica :  including  Laboratory  Exercises 
in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert  A. 
Hatcher,  Ph.  G.,  M.  D.,  of  Cornell  University  Medical  School,  New 
York  City ;  and  Torald  Sollmaxn,  M.D.,  of  the  Western  Reserve  Uni- 
versity, Cleveland,  Ohio.    i2mo  of  41 1  pages.    Flex,  leather,  $2.00  net. 

JUST   ISSUED— A   NEW   WORK 

This  work  is  a  practical  text-book,  treating  the  subject  by  actual  experimental 
demonstrations.  Part  I.  comprises  a  guide  to  the  study  of  crude  drugs,  both 
official  and  unofficial.  In  Parts  II.  and  III.  the  histologic  and  chemic  examina- 
tions of  drugs  are  considered  in  a  scientific,  yet  clear  and  simple  manner. 

Eichhorst's  Practice 

A  Text=Book  of  the  Practice  of  Medicine.  By  Dr.  Hermann 
Eichhorst,  University  of  Zurich.  Translated  and  edited  by  Augus- 
tus A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine,  Philadelphia 
Polyclinic.  Two  octavos  of  600  pages  each,  with  over  150  illustra- 
tions.    Per  set :  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco,  #7.50  net 

Bulletin  of  Johns  Hopkins  Hospital 

"  This  book  is  an  excellent  one  of  its  kind.  Its  completeness,  yet  brevity,  the  clinicai 
methods,   the  excellent    paragraphs    on    treatment    and  watering-places,  will    make   it   very 

desirable." 


Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.D.,  Emeritus  Pro- 
fessor of  Medicine  in  Rush  Medical  College,  in  affiliation  with  the 
University  of  Chicago.  i2mo  of  302  pages,  illustrated  Cloth. 
#1.50  net. 

Medical  News,  New  York 

"  Thoroughly  representative  of  our  practical  methods  of  diagnosis  and  treatment  of  the 

disease." 


12  SAUNDERS'  BOOKS   ON 

Thornton's   Dose-Book 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  Thorn- 
ton, M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson  Medical 
College,  Phila.  Post-octavo,  362  pages,  illustrated.  Flexible  Leather, 
$2.00  net. 

Second  Edition,  Revised  and  Enlarged 

In  the  new  edition  of  this  work,  intended  for  the  student  and  practitioner, 
additions  have  been  made  to  the  chapters  on  "Prescription-Writing"  and 
'  ■  Incompatibilities, ' '  and  references  have  been  introduced  in  the  text  to  the 
newer  curative  sera,  organic  extracts,  synthetic  compounds,  and  vegetable  drugs. 
To  the  Appendix,  chapters  upon  Synonyms  and  Poisons  and  their  antidotes 
have  been  added,  thus  increasing  its  value  as  a  book  of  reference. 

C.  H.  Miller.  M.  D.. 

Professor  of  Pharmacology,  Northwestern  University  Medical  School,  Chicago. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recommend 
the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text-books." 


Barton  and  Wells'  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and  Thera- 
peutics, Georgetown  University,  Washington,  D.  C. ;  and  Walter  A. 
WELLS,  M.  D.,  Demonstrator  of  Laryngology,  Georgetown  University, 
Washington,  D.  C.  i2mo  of  534  pages.  Flexible  leather,  $2.50  net; 
with  thumb  index,  $3.00  net. 

"  We  can  easily  see  the  value  of  such  a  book,  and  can  certainly  recommend  it  to  our 
readers." — Boston  Medical  and  Surgical  Journal. 

Mathews*  How  to  Succeed  in  Practice 

How  to  Succeed  in  the  Practice  of  Medicine.  By  Joseph  M. 
MaTHEWS,  M.  D.,  LL.D.,  President  American  Medical  Association, 
i8o,8-'99.     i2mo  of  215  pages,  illustrated.     Cloth,  $1.50  net. 

JellittVs  Pharmacognosy  just  issued 

An  Introduction  to  Pharmacognosy.  By  Smith  Ely  Jelliffe,  Ph.  D., 
M.  D.,  Professor  of  Pharmacognosy  and  Instructor  in  Materia  Medica  and 
Therapeutics  in  Columbia  University  (College  of  Physicians  and  Surgeons), 
New  York.     Octavo  of  265  pages,  illustrated.     Cloth,  S2.50  net. 


THE  PRACTICE   OF  MEDICINE.  13 

Gould   and   Pyle's 
Curiosities  of  Medicine 


Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.  D.,  and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
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Popular  Edition  :  Cloth,  $3.00  net ;  Sheep  or  Half  Morocco,  84-00  net 

As  a  complete  and  authoritative  Book  of  Reference  this  work  will  be  of  value 
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general  scientific,  sociologic,  and  medicolegal  topics  ;  in  fact,  the  absence  of  any 
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literary  innovations  of  the  day. 

The  Lancet,  London 

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Saunders*  Pocket  Formulary 

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Johns  Hopkins  Hospital  Bulletin  possible.    It  is  remark- 

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able  how  much  information  the  author  has  succeeded  m  getting 


i4  SAUNDERS'  BOOKS   ON 

Sollmann's  Pharmacology 

Including  Therapeutics,  Materia  Medica,  Pharmacy, 
Prescription -writing,  Toxicology,  etc. 


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Assistant  Professor  of  Pharmacology  and  Materia  Medica,  Medical 
Department  of  Western  Reserve  University,  Cleveland,  Ohio.  Hand- 
some octavo  volume  of  894  pages,  fully  illustrated.     Cloth,  $3.75  net. 

A   NEW   WORK— RECENTLY   ISSUED 

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author  bases  the  study  of  therapeutics  on  a  systematic  knowledge  of  the  nature 
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pharmacology  and  practical  medicine. 

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Butler's   Materia   Medica 

Therapeutics,  and  Pharmacology 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 

By  George  F.  Butler,  Ph.  G.,  M.  D.,  late  Prof,  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago, 
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PRACTICE,  MATERIA   MEDICA,  Etc.  15 

The  American  Pocket  Medical  Dictionary.  4th  Ed.  Recently  issued 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
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Medical  Diagnosis.  By  Dr  Oswald  Vierordt,  Professor  of  Medicine,  Univer- 
sity of  Heidelberg.  Translated  from  the  fifth  enlarged  German  edition  by  Francis 
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Cohen   and   Eshner's   Diagnosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
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American  Medical  Association. 

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«-  UMtinn-TROAn  (Massage  and  Medical  Gymnastics).  Ry 
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16  SAUNDERS'    BOOKS   ON  PRACTICE,  Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr. 
Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.,  Pro- 
fessor of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  182  colored  figures  on 
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Lockwood's  Practice  of  Medicine.  Revbed  and  Enlaced 

A  Manual  of  the  Practice  of  Medicine.  By  Geo.  Roe  Lockwood,  M.  D., 
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Salinger  and  Kalteyer's  Modern  Medicine 

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Medicine,  Jefferson  Medical  College;  and  F.  J.  Kalteyek,  M.  D.,  Demonstrator  of 
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trated.    Cloth,  $4.00  net. 

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and  Practice  of  Medicine,  Cooper  Medical  College,  San  Francisco. 

Keating's  Life  Insurance 

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Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  A.  M.  Corwin,  A.  M., 
M.  D.,  Professor  of  Physical  Diagnosis,  College  of  Physicians  and  Surgeons,  Chicago. 
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American  Text- Book  of  Theory  and  Practice 

American  Text-Book  of  the  Theory  and  Practice  of  Medicine.     Edited 

by  the  late  William  Pepper,  M.  D.,  LL.  D.,  Professor  of  the  Theory  and  Practice 

.     of  Medicine  and  of  Clinical  Medicine,  University  of  Penna.     Two  handsome  imperial 

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Practice  of  Medicine,  University  of  the  City  of  New  York. 

Stevens'  Practice  Of  Medicine.     Sixth  Edition,  Revised— Recently  Issued 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Steyens.  A.  M.,  M.  D., 
Professor  of  Pathology,  Woman's  Medical  College,  Phila.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post-octavo,  556  pages  ; 
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"An  excellent  condensation  of  the  essentials  of  medical  practice  for  the  student.,  and  may  be  found 
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J  J  0  5 


Date  Due 


— 9tP — 

I  1973 

printed  in  o.s.*.            CAT.   NO.   24    161               fiW 

A  000  500  866  9 


QS17 

S387a 

1905 

Schultze,  Oskar. 

Atles  and  text-book  of  topographic 
and  applied  anatomy 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


